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Treating Pain Psychologically

One of the goals of rigorous science is to disentangle various causes so we can establish exactly where the lines of cause and effect are. In medicine this allows us to then optimize the real causes (what aspect of treatments actually work) and eliminate anything unnecessary.

Eliminating the unnecessary is more than just about efficiency – every intervention in medicine has a potential risk, so this is also about risk reduction.

It often seems to me that the goal of “alternative” medicine is to blur the lines of cause and effect, to exploit non-specific effects in order to promote a useless but profitable ritual (acupuncture comes to mind).

Pain is the area most susceptible to such blurring of lines. Pain is a complex combination of physiological and psychological effects. Physiologically pain is produced by tissue damage or pathology provoking pain signals in sensing nerves (nociceptive pain). This type of pain serves a protective purpose, and does not last beyond the pathology itself. There is also neuropathic pain, in which pain arises abnormally from within the nervous system itself. This type of pain is chronic and not protective.

Pain signals are conducted to the brain where they are perceived. There are two components to this perception, with their own neuroanatomical correlates. The first type localizes the pain – where exactly in the body the pain originates. The second adds emotional context to the pain – it makes it hurt. Pain would not serve its function if it didn’t really bother us or force us to pay attention.

Interestingly, opiates are more effective at suppressing the emotional aspect of pain. Therefore it is common for patients on opiates for severe pain to report that they can still feel the pain, it just doesn’t bother them.

At every step in the process, pain intensity can be modulated. Further, pain is closely tied with attention – the pain hurts more when we attend to it, and less when we attend to something else. Anxiety and depression also increase the subjective experience of pain.

Therefore, a multidisciplinary or total approach to treating pain can address treating the underlying pathology (always the first priority), inhibiting the physiological and neurological production and conduction of pain, reducing the brain’s perception of pain, and modulating all of the psychological aspects of attending to pain and its emotional comorbidities.

When doing pain research it is critical to isolate, as much as possible, all of these various effects. Otherwise no conclusions can be drawn about the effect of any one aspect of the treatment. The kind attention of the practitioner and the hope of a treatment effect alone will likely result in the reporting of reduced pain.

This is all closely related to the concept of “placebo effects.” Operationally, in medical research “placebo effects” are everything other than a physiological response to the active treatment being studied. However, when treating pain these other effects could not only be useful, but already be part of multidisciplinary pain treatment. These non-specific effects, however, do not justify the active treatment, unless the active treatment is shown to independently contribute to the overall pain reduction.

Again taking acupuncture as an example – the point by proponents is often made that even if acupuncture is no more effective than placebo (it isn’t), that’s OK, because placebo effects are useful in treating pain. But acupuncture is not delivering these placebo effects, it is the ritual surrounding acupuncture that is primarily doing so. The sticking of needles into specific points does not appear to add anything to the overall effect.

If we want to maximize the utility of the psychological aspects of pain treatment, then let’s optimize those and dispense with the elements that are adding nothing. There are attempts to do just that. Some methods already in use include biofeedback, stress management, and cognitive-behavioral therapy (CBT).

A recent study looks at combining such methods into a protocol the researchers call “Mindfulness-Oriented Recovery Enhancement (MORE).” The technique is described as:

Mindfulness involves training the mind to increase awareness, gain control over one’s attention and regulate automatic habits.
Reappraisal is the process of reframing the meaning of a stressful or adverse event in such a way as to see it as purposeful or growth promoting.
Savoring is the process of learning to focus attention on positive events to increase one’s sensitivity to naturally rewarding experiences, such as enjoying a beautiful nature scene or experiencing a sense of connection with a loved one.

In other words, meditation and CBT, so it seems like a new spin on these established techniques. That is not necessarily a criticism, however, if the goal is to optimize the effectiveness of non-pharmacological techniques in managing chronic pain.

One of the biggest complications in treating chronic pain is opiate overuse. This occurs because of tolerance, the drugs work less and less well over time so doses have to increase. Also opiates are psychologically addicting, and patient often self-medicate with them to treat the anxiety and depression that goes along with the pain.

The researchers in the above study also looked at opiate overuse as an outcome. They found:

MORE participants reported significantly greater reductions in pain severity (p = .038) and interference (p = .003) than [support group (SG)] participants, which were maintained by 3-month follow-up and mediated by increased nonreactivity and reinterpretation of pain sensations. Compared with SG participants, participants in MORE evidenced significantly less stress arousal (p = .034) and desire for opioids (p = .027), and were significantly more likely to no longer meet criteria for opioid use disorder immediately following treatment (p = .05); however, these effects were not sustained at follow-up.

This is a preliminary, but reasonably designed and powered study. The results are encouraging, but all the caveats apply until it is properly replicated.

The one discouraging result is that reduction in opiate overuse was not sustained. One rule of thumb in pain research is that what patients do is likely more significant than what they say. If they report less pain but use the same amount of pain medication, their report is likely biased.

Conclusion

It’s time to move past the empty rhetoric and deceptive shell-game of “placebo medicine.” Non-specific effects of a positive therapeutic intervention, combined with specific psychological interventions, can reduce the experience of pain and improve quality of life. This should not be used to justify useless rituals and the magical thinking (and risks, however small) that go along with them.

Rather, researchers interested in such effects should study them directly and figure out how to maximize their usefulness and free them from the pre-scientific rituals in which they are often embedded.

Posted in: Clinical Trials, Neuroscience/Mental Health

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246 thoughts on “Treating Pain Psychologically

  1. goodnightirene says:

    I’ve alluded to this before, but I’ll be direct: There is a great deal doctors could do to stimulate the placebo effect without any ruckus. At the acupuncture (Ac) clinic one is treated to soothing music (not Pharma-sponsored tv blaring drug ads), soft light (not blinding fluorescents), invited to lie on a comfortably padded table, covered with a warm blanket or sheet, engaged in small talk at length with the “doctor” which will include a sympathetic response to one’s slightest complaint, and endlessly reassured that things are bound to improve now that the patient has “empowered” herself–or some other related babble. No ugly paper “gowns”, no weigh-in, no sitting bored stiff in an empty exam room (thank goodness for iPhone games), no getting cut off every time you try to answer the question at a bit too much length, and now the latest–no sitting there whilst the doctor types furiously into the computer (at least we used to get a bit of eye contact).

    And we wonder why people come away from the Ac “clinic” feeling much better!

    My point is (and you are probably wondering) that there are things that could be done to make people feel more–well, more HUMAN in their medical experiences–even with the time constraints our system has placed on the office visit.

    If you take a look at the SCAM components that are opening up at various institutions, I think you’ll see that they look a lot like massage or Ac parlors (I really can’t call them clinics)–at least the ones in my area do. I think a good example of what I’m talking about is the transformation in mammogram offices in the last 15 or 20 years. They used to be the same as any other x-ray lab, but now they are all soft pink, comfy chairs, wallpapered, full of individual lockers. You get a gown AND a robe with a private changing area. A very nice nurse comes to talk with you individually about the whole business and asks kindly if you have any concerns and so on. The technician is concerned to the point of being obsequious. If there is any negative result whatsoever, you get even more lavish special attention. Does any of this change the results of the mammo? No, but it makes the experience much more tolerable for a lot of women and has resulted in much better compliance (I think).

    Personally I find it insulting and condescending, but that’s just me. :-)

    1. Sawyer says:

      “not Pharma-sponsored tv blaring drug ads”

      Forget about the ads, the mere act of having a blaring television is not something that improves patient experience. The last time I went to a doctor there was a television in the waiting room turned up WAY too loud. I suppose the intention is to provide distraction or entertainment for people that are nervous about their appointment, but I found it put me in a very foul mood (it was also 4pm on a weekday, so he-who-shall-not-be-named was on). Having a few good coffee table books available instead would have been a tremendous improvement.

      1. mousethatroared says:

        Years ago I went to the E.R. for severe stomach pain. They suspected gall stones and sent me for an ultra-sound. The waiting room had a TV with Jerry Springer playing, loud volume. I couldn’t stand up to turn it off, due to the pain and being tangled with an IV – it was like the opposite of a positive distraction, you focus on your physical pain to take your mind off the intellectual assault. :)

        On the other hand, I once had an MRI technician who offered headphones with a choice of music. They had a good metal station that nicely complemented the thumping of the MRI. MRI’s are not typically painful, but with a bad neck or shoulder, lying still on your back for an extended period of time is not a piece of cake. The music was considerate and helpful..

        1. Frederick says:

          At least if that tv was playing another Jerry SEINFELD, not springer, your experience will have been better!

          1. mousethatroared says:

            Frederick “At least if that tv was playing another Jerry SEINFELD, not springer, your experience will have been better!”

            Probably better, but when I’m in pain I have a low tolerance for laugh tracks.

            My personal preference would be nothing on the TV but a bit of non intrusive music. Although I appreciate that some people like the distraction of TV. Maybe a good compromise would be TV going with optional headsets, like on a plane…although then the hospital has to think of bacterial/viral transmission on headsets, I suppose.

            Nature programs are nice, except the obligatory wildebeest being massacred by a crocodile.

            Maybe I’ll just try to avoid hospital imaging waiting rooms. ;)

        2. Kathy says:

          Last time I went to my doctor, the whole waiting room had been changed round. The chairs were in seven or eight rows, all facing the TV. What it reminded me of was a church, with the TV where the pulpit would be. The moral of the story … no idea. Maybe there isn’t one.

      2. Donna B. says:

        Car dealers are figuring this out. When I take my car in for an oil change, I have a choice of the “quiet” waiting room or the one with the TV.

        1. irenegoodnight says:

          Oh Donna B, please tell me the name of your car dealership! Mine only has blaring TV with The View or a soap or another corner where the hip hop music will deafen you for life. I go outdoors, but that can get tricky when it’s nine degrees (without the windchill). I feel better (placebo?) just knowing that I am not the only one who finds TV annoying–clinic or dealership.

          @Mouse
          What a HORRIBLE ordeal with your stomach pain. That was painful just to read.

          @Sawyer
          I used to wait in the hall at my former medical clinic which had one of those Pharma-sponsored TV’s that ran a loop of ads for “lifestyle” drugs (nowadays even the vet has one of these!). There are never magazines anymore–“germs” I’m told. I take my headphones and crank up my own music enough to drown out the TVs when I encounter them. My newer clinic doesn’t have TV and does have a few magazines. Best of all, you never wait more than about two minutes!

          I accompanied my neighbor to the ER a while back and there was a TV (up high) right across from the reception desk that was so loud I had to shout the woman’s name at the desk person–who didn’t seem the slightest bothered by the blaring TV. Sadly, the other people waiting were all transfixed on the tube–which was playing an infomercial. :-(
          ——-
          I guess TV is “mainstream” medicine’s answer to the spa-like setting of the alties. No wonder we’re losing this game!

          1. CHotel says:

            I always feel spoiled during discussions about how crappy waiting rooms are. My physician’s clinic is in the hospital we both work at, so I can just check in for my appointment, ask them to page me when she is ready, and then go back to work for awhile. The only waiting I ever do is in the exam room. (I can do the same thing with lab and radiology too; my last appointment plus x-rays took about 30 minutes out of my work day)

            I don’t think there are any TVs in the clinic though, I don’t remember seeing any.

        2. Frederick says:

          My honda dealer are nice people, but the tv is always on a Sensationalist, kind of right wing, news channel, Thank god of google for android.

    2. Stephen S. Rodrigues, MD says:

      Placebo is very effective in the office setting and we use it in everyday practice either by omission or commission or deception.
      Giving an antibiotic for a cold.
      Getting an MRIs for someone who has a headache.
      Performing a Laparoscope in a chronic pelvic pain case.

      In the case of Acupuncture it is truth and fiction. In the proper hands truth!

      1. windriven says:

        Where are your top ten, Needleman? Let’s talk reality instead of your usual tired delusions. Your ten. My ten. We’ll compare.

        1. Stephen S. Rodrigues, MD says:

          Amer Acad medical Acup

          1. windriven says:

            That means nothing. Are you incapable of understanding the challenge or too cowardly to address it?

            1. Nashira says:

              I am sincerely starting to think that he’s incapable of understanding it.

    3. Stephen S. Rodrigues, MD says:

      Please guys don’t use Acupuncture or acupuncture name in vain. You have proven you have no idea what is in or is not. Find another term that is appropriate like,
      Science Based Medicine Cultist — which is definitely a farce and not credible.

      1. MadisonMD says:

        Did your mind belch something, SSR? Please read what you write before you hit “Post.” It doesn’t even make sense.

        Acupuncture or acupuncture name in vain. You have proven you have no idea what is in or is not.

        You’ve complained we don’t know what “Acupuncture” is a dozen times. But just as many times you have refused to actually tell us what it is. So, for now, I go with Mr. Webster, OED, and American Heritage. They are far more reputable sources than you. Moreover, they actually provide definitions… concordant definitions, even. There is no difference between acupuncture and Acupuncture except that, grammatically, the latter is preferred when starting a new sentence.

      2. windriven says:

        Top Ten, Rodrigues. Let’s have ‘em. Real proof, not idle claims.

      3. MadisonMD says:

        I second windriven’s request. Time to compare top ten, SSR.

      4. Andrey Pavlov says:

        I don’t read SSR’s stuff – it is just too inane and an utter waste of my life – but every once in a while a short one grabs my eye. Like this one.

        I just can’t fathom the drivel coming out of this guy. And very persistent about it.

        1. Stephen S. Rodrigues, MD says:

          The web is vast and you can find most any information. Due diligence is your responsibility. Even if you choose not to read my ideas.

          A true scientist will look at a word in much more detail than a definition.

          Acupuncture, the word is analogous to the word car. There are many types of cars as there are many types of Acupuncture. Then if an owner wants to modify his car he or she can make all types of changes base within the laws of nature and the discipline or just drive is as it is. The types are limited but the variations are unlimited.

          1. MadisonMD says:

            There are many types of cars as there are many types of Acupuncture.

            Yep, and here’s the automotive analog to SSR’s type of “Acupuncture.”

  2. Adam Rufa says:

    This is a bit picky but I think it is important because it gets to the root of the misunderstanding of the pain system. The statement “Pain signals are conducted to the brain where they are perceived” is bringing us back to the incomplete Cartesian model of pain. The peripheral nervous system does not transmit “pain signals” no more than it transmits vision or hearing. The ears convert sound waves into electrical input which our brain then combines with other inputs and creates the output of hearing. This is obvious when you consider brain mistakes such as the McGurk Effect (http://www.youtube.com/watch?v=G-lN8vWm3m0).
    The pain system is no different. The peripheral nervous system transmits a “nociception signal” (not a pain signal) which is then processed by the brain along with many other inputs. If the “threat level” is high enough the brain will produce the perception of pain. So calling nociception signals, pain signals, turns pain into an input to the brain rather than an output of the brain. This can then lead to a vary narrow view of pain, which I know this article is not promoting.

    I realize this is picky but I do think it is an important point.

    Here is more on the subject: http://www.bodyinmind.org/teaching-people-about-pain-part-1/

    1. Andrey Pavlov says:

      Pedantic and picky, but I agree – both correct and important. Though I think that Dr. Novella’s intent was in concordance with your comment.

      1. Adam Rufa says:

        I totally agree that Dr. Novella’s intent was in concordance with the comment.

        1. Reasonable point, but I think the lingo is not quite so straight forward. The term “pain” is used to refer to dedicated peripheral pathways, not just cortical perception. Nociceptive is very specific, but not in the way you suggest. Nociceptive really refers the pain receptors that originate the signal. Neuropathic pain typically originates proximal to these receptors, but still generates the same signal (can be both peripheral or central, but pre-cortical).

          I don’t think use of the term “pain” is the problem, as long as you distinguish the generation of pain signals and the ultimate cortical perception of that pain, including the various elements of perception (attention, emotion, localization).

          I don’t mind fighting semantic wars, as long as they’re useful. Here the distinction is not as clear as you are making it, in my opinion.

          1. Adam Rufa says:

            But don’t you agree that pain is a perception, hence an output from the brain not an input?
            I agree that in the past, prior to our improved understanding of the pain system, the term “pain” was used to describe the input to the brain. I also agree that the term “pain signal” is not the major problem, however it indicates that pain is an input to the brain which may be misleading to people who do not have a nuanced understanding of pain. We realize that it is common for our brain to get nocicepion input (our danger signals) yet never trigger the pain response. My experience is that many healthcare professionals don’t understand this.

            Here is a interesting questionnaire, developed by Loramir Moseley, which assess current pain science knowledge.

            http://cdn.bodyinmind.org/wp-content/uploads/Revised-neurophysiology-of-Pain-Questionnaire-1.pdf

          2. TsuDhoNimh says:

            perception of that pain, including the various elements of perception (attention, emotion, localization).

            Interesting that someone who gets injured skiing or snowboarding, or overdoes it with the weight machine has a totally different reaction to that pain than if it was from other causes, such as a work-related injury.

            1. Stephen S. Rodrigues, MD says:

              So back pain is not so easy to defined even for the person who is suffering with the pain. so how does one even design a study in these circumstance and how valid are the conclusions?

              SBM and the scientific methods used to study such treatment options have to take into account these all these variations. This would mean most studies would have to be redesigned and all prior studies inconclusive.

              This is where strict dogmatic science methods are inherently inconsistent in the study of alternative medicine.

              1. Sawyer says:

                No, yet again you’ve got this completely backwards. The fact that pain perception is subjective and difficult to measure is exactly why we need better science-based methods of studying it. If you relax the standards of evidence you end up making tons of superficial “improvements” that look like they are promising but ultimately lead nowhere in the long run. If you go in the other direction and push for a truly multi-disciplinary, scientific approach to studying pain the progress is slower but it’s real and it’s permanent. We have the basic tools of neurology, psychology, and anatomy needed to do this. The biggest barrier to progress is not science, but the CAM researchers refusing to cooperate with the rest of the medical community.

              2. Stephen S. Rodrigues, MD says:

                @sawyer (my I ask who are you?)
                “better science-based methods”
                The methods are already standardized and “classic,” what we have issues with are how to apply those principles, definitions and what the conclusions mean. This maybe impossible.

                I do know, beyond a shadow of a doubt a few vital characteristics of the primary source of myofascial pain;
                It’s a sinister devilish apparition because the energy impulses are variable, radiate, migrate erratically and dependant on season, time of day and stress levels.
                It can NOT found by any high-tech imagery or scan.
                It can only be found and treated by the try and see hands-on approach as in the art of medicine.
                It will torment the patient until it is effectively treated.

                Backwards is a relative term, I consider myself in the correct position.

              3. Sawyer says:

                @ SSR

                “It can only be found and treated by the try and see hands-on approach as in the art of medicine.”

                I’m not talking about removing the ‘art’ of medical pain treatment. It has always required a very personal approach and probably always will. I’m talking about careful statistical evaluations of which treatments are most likely to succeed (science), continuous refinement of how pain scores are used based on what we know about psychology and neurology (more science), and abandoning techniques that have zero anatomical plausibility (even more science). You have stated numerous times that you reject all of these suggestions, presumably because you don’t know how to work with people in other fields to address these issues.

                The result of your approach is that even IF what you do has some benefit (which I vehemently disagree with), you are cursing the next generation of pain sufferers to the same crappy techniques we already use. Just because you are not creative enough to come up with a more robust understanding of the causes and prevention of pain, don’t think others lack the insight to do so.

              4. WilliamLawrenceUtridge says:

                my I ask who are you?

                Allow me to translate:

                “Please tell me your credentials, so I’ve got another reason to ignore your points and discount your opinions.”

                The methods are already standardized and “classic,” what we have issues with are how to apply those principles, definitions and what the conclusions mean. This maybe impossible.

                Methods change and improve as new information comes to light, and your substitution for scientific research and reasoning, your gut instinct, isn’t an adequate substitute.

                I do know, beyond a shadow of a doubt a few vital characteristics of the primary source of myofascial pain

                Yeah, that’s really the problem. You know no doubt, when you should have a lot of it because our understanding of the issues is blurry and imperfect. The exact conditions where a non-arrogant doctor would have doubts and questions rather than dogmatic certainty.

            2. mousethatroared says:

              @TsuDhoNimhWell, – I suppose lots of things are interesting. But I don’t find it very surprising that a traumatic injury from a recreational activity that one can discontinue easily would have generally different outcomes than pain from an on the job injury or activity.

              Comparing a professional painter’s cervical radiculopathy to a broken collar bone in a snow boarder is a bit apples to oranges.

            3. daedalus2u says:

              Actually the type of pain that is most susceptible to the placebo effect is acute pain from wounds received in wartime. Soldiers wounded in battle receive much more pain relief from placebo injections than do civilians with similar injuries from civilian accidents.

              The explanation is due to differential expectations. The soldier has already survived the battle. He/she can relax. The civilian is just starting a long and unpleasant course of healing from an unexpected injury.

    2. mousethatroared says:

      Very Interesting! Glad you added it.

  3. Lost Marble says:

    I’ve had a burning question about how to treat psychological pain – it is complicated enough to separate warm and fuzzy feelings from actual pain decrease when pain is physical. In a patient who is depressed, the purpose is kind of warm and fuzzy feelings – what measure is there to evaluate if homeopathy did anything for my anxiety, or if I left acupuncture feeling awesome – did it really ‘work’? I know those didn’t, and I know they’re bull, but there are many others.

  4. Alex T says:

    Very interesting stuff. I’m curious now, have there been any good studies which tried anti-anxiety meds in conjunction with opiates (or other pain killers)?

    I’ve heard from medical marijuana patients who use it for chronic pain to apparently good results. With all of the hype & misinformation about marijuana I’m never sure what’s real or not. Has anyone looked into this and if it does help, is it working by reducing anxiety or by reducing the pain?

    It sounds like the studies into the way we respond to pain can lean to novel ways of treating it that hit it from many sides to not just reduce the pain but also reduce the way we perceive or interpret it.

    1. DJDenning says:

      When I was in graduate school a couple of years ago, I looked at RCTs that examined the efficacy of cannabinoids in the treatment of neuropathic pain. There was some good evidence for them, particularly for central pain, a kind of pain suffered most commonly by people with multiple sclerosis. But it’s no better than placebo for acute pain.

      That said, I wonder if the whole mythology around medical marijuana heightens its placebo effect when treating pain.

    2. Stephen S. Rodrigues, MD says:

      Yes … read about Cymbalta.

      1. windriven says:

        Top ten disease entities that acupuncture has mastered and transformed the human condition versus top ten for medicine. Enough of your chit-chat, let’s have the proof.

  5. zoe says:

    The one discouraging result is that reduction in opiate overuse was not sustained.

    I assume that this is due to falloff in patient performance of the strategies they learned. Presumably whatever protective power is conferred by the effects of mindfulness/CBT/meditation persist only as long as the patient practices those strategies. Proponents of CBT/mindfulness frame such facts as evidence that CBT/mindfulness are lifestyle choices, not “cures,” so to speak. It’s the same thing we would see regarding the effect of exercise, diet changes, etc. If you fall off the wagon, the benefits stop.

    If my assumption is wrong, and these patients were continuing to practice the CBT/mindfulness strategies at the follow-up period but no longer finding benefit from them, then that would seriously call into question the efficacy of deliberate psychological therapy techniques. One of the theoretical prerequisites of CBT (and meditation) is that deliberate mental activity can affect emotional experience over the long term. If that is not the case, then even the purported psychological benefits of these techniques should be called into question. To me, this is relevant to the use of CBT/mindfulness for the symptoms of mental illness, as well as for neuropathic pain.

  6. steney01 says:

    “Reappraisal is the process of reframing the meaning of a stressful or adverse event in such a way as to see it as purposeful or growth promoting.”

    I have a hard time believing a patient is going to successfully re-frame the meaning of their debilitating chronic pain as growth promoting. Maybe they improve their ability to work through their problems and that’s nice, but if the pain relief effect is highly transient and they go right back to the opioids (which the study states is the case) then what was accomplished? How is this different from the patient who feels good for a day after their acupuncture?

    1. mousethatroared says:

      I have a hard time believing a patient is going to successfully re-frame the meaning of their debilitating chronic pain as growth promoting.

      If you are curious, the book Stumbling upon Happiness (Daniel Gilbert) has some good examples of people who have chronic conditions, disabilities or painful conditions and have grown to see the positive aspects of their circumstances.

  7. Mark A Crislip says:

    I never knew that “opiates are more effective at suppressing the emotional aspect of pain.”

    When I had abdominal surgery I distinctly remember hitting the demerol PCA pump post op and the pain mostly remaining but no longer caring that I hurt. It was like the pain belonged to someone other than me. It is one of several dissociative events I have had from medications, the others being from nitrous for a wisdom tooth removal and indomethacin. They are odd.

    And when I awoke from the herniated disc surgery to be free of the radiculopathy that had ground on me for 9 months, I was so euphoric I never took any meds for the incision pain. That was nothing compared to the C5 pain I had had.

    Explains my experience; I will have to look more into the issue some day.

    1. irenegoodnight says:

      Nitrous! Definitely my drug of choice–alas, I only had four wisdom teeth and one root canal with complications. :-)

      1. Stephen S. Rodrigues, MD says:

        Nitrous does have some neurotransmitter stabilizing effects!
        I use it in my office to help some in pain and PTSD!

    2. ConspicuousCarl says:

      I forget the morphine-like drug I got for my wisdom teeth, but it was the same thing. Not numbness at all. It didn’t quite “hurt”, but yanking my teeth out was more like a pulling a booger. I could feel it happen, and even hear it, but it didn’t bother me at all. Neither the feeling of a tooth sliding out nor the idea of it being done seemed like anything to care about.

      Contrast that with a novocaine needle–the very idea of getting stuck with it, even for a brief sting, freaked me out every time. And the grinding sound, even though I couldn’t feel it, was inescapable in my mind and horrific.

    3. Kathy says:

      “That was nothing compared to the C5 pain I had had.”

      Been there, done that, got the hair shirt too! Same op and same reaction. I took the pain pills to keep the nurses happy … they were SURE I must be hurting, poor lassies. After I went home I took them to keep my mother happy. After my mother left I just forgot about them. Just not being woken up four times a night with racking pain in my leg was a glorious experience.

    4. Stephen S. Rodrigues, MD says:

      In some cases small, patient will have to be on opiate life long as like a antidepressant or anti anxiety or bipolar stabilizers … I’ve seen it!

      May have a lot to do with the neurotransmitter effects plus the dramatic withdrawal upheaval being off of the meds will evoke.

      ? PTSD like effect,

      1. windriven says:

        All talk, all the time. But nothing but silence when it comes to measuring up. Top ten, Stevie. Yours and mine.

      2. Adam Rufa says:

        What about Opioid induced hyperalgesia?

  8. jacobv says:

    Sometimes there are bigger issues in managing pain than just daily functioning and avoiding opiate dependence; especially when you consider the significantly higher suicide attempt and completion rates among those with certain chronic pain conditions. Also those individuals who have an ongoing mental health disorder as well as a chronic pain condition are at a significantly higher risk of suicide than those with just a chronic pain condition. IMO any MD treating chronic pain needs to make sure they discuss any ongoing mental health issues with their patients and communicate with the patients mental health provider to address these risks. And I would think that integration of CBT in chronic pain treatment should provide an opportunity for suicide screening by a mental health provider among these patients.

    http://journals.lww.com/clinicalpain/Abstract/2008/03000/Chronic_Pain_Conditions_and_Suicidal_Ideation_and.4.aspx

  9. adiemusfree says:

    I couldn’t agree more – thoughtful use of the “meaning response” aka placebo could reap great rewards in chronic pain management – but I don’t think the medical profession is yet ready to do so. There are a great many biomedical practitioners who fail to acknowledge the brain as a critical part of pain, many more who don’t focus on disability and distress reduction but focus exclusively on “reducing pain” without looking at how and why people have trouble with their pain.
    People seek treatment for pain more because of interference with daily function than because of pain intensity – it’s not pain that’s the problem, as much as what pain represents. This is why so-called psychological interventions have small but consistent effects. Combined with learning to successfully increase activity level, learning to LIVE well despite pain, and people don’t have to suffer. And the pain can remain present, even at the same intensity.
    I’d also like to concur with your correspondent about “pain signals” – nociceptive signals perhaps, but until this reaches consciousness it is not pain. A critical point, not trivial, because pain is a biopsychosocial experience. If it wasn’t, we would have no explanation as to why people have tattoos, do marathons, eat chilli, do body suspensions and even give birth without pain relief.

    1. Andrey Pavlov says:

      There are a great many biomedical practitioners who fail to acknowledge the brain as a critical part of pain

      I am sure there are crappy practitioners just like there are crappy people in every field, but your entire rant is incongruent with the mainstream of reality. Melzack’s theories have been around since the 70′s and have only been more and more supported, used, and referenced.

      many more who don’t focus on disability and distress reduction but focus exclusively on “reducing pain” without looking at how and why people have trouble with their pain.

      Some 30-40ish years ago pain was indeed just that. We discussed the inflammation and pain of joints using latin words – rubor, dolor, calor, tumor. But even Galen looked at functio laesa; loss of function. And how your pain and health status impacts your daily functioning is a huge part of making clinical decisions.

      A critical point, not trivial, because pain is a biopsychosocial experience.

      Precisely. Which is why the biopsychosocial model of health has been taught in medical schools for going on 3 decades now….

    2. mousethatroared says:

      You are saying that psychological interventions yield small but consistent benefits, but then say that thoughtful use of the “meaning response” could reap great benefits.

      How are you interpreting the potential for great benefit from evidence that indicates small or short term benefit?

      Personally, I’m kinda glad my pain clinic gave me a cervical epidural steroid shot for my radiculopathy rather than a reinterpretation of the meaning of pain. Not that I’m against mindfulness and CBT, but I prefer to try the method with the highest chance of large benefit first.

      1. Stephen S. Rodrigues, MD says:

        Oooo steroids in the spine will lead to arachnoiditis and premature spinal degeneration and vertebral body collapse. Why won’t you get more of them?

        1. mousethatroared says:

          Alarmist much? I believe that the risks (possible risks, not certainties as you state them) are predominately with long term steroid use or higher numbers of spinal punctures. Which is why my doctors are careful about limiting steroid use and recommend no more than three epidurals, spaced for safety. And, I can’t have premature spinal degeneration, when I already have a mature degenerative spine, now can I?

          Why won’t I get more of them…no need at this point. If the pain/radiculopathy comes back significantly I’ll probably be heading the way of Mark Crislip and Kathy (and both of my older sisters…gotta love those genes) with surgery, but I’ll cross that bridge if I come to it.

          1. Stephen S. Rodrigues, MD says:

            Premature in this case means atrophy and degeneration faster than the normal rate.
            Oh steroids will cause a spinal abscess (hopefully sterile) and Acrachoiditist … ouch.

            The atrophy from steroids in a single location can cause the tendons and ligaments to spontaneously detach from the bone. In these cases the vertebrae will just slip and you may be paralysed. Definitely prone to fractures and curvatures.

            1. mousethatroared says:

              Once again, you are confusing the side effects of long term steroid exposure with that of one to three epidurals.

              Either you are incredibly clueless or you are being intentional deceptive.

              And “hopefully sterile” Please, that sort of innuendo is just insulting to the incredibly meticulous, safety conscious and considerate team (doctor, nurse, radiologist and pre and post procedure nurses) that did my procedure.

              You know, I’ve pretty much ignored your comments up until now. But, from this brief exchange, I can understand the strong reaction of the other regulars here.

              I have no interest in your ignorant advice, please unlatch your lamprey like attention from my comments.

              1. Stephen S. Rodrigues, MD says:

                This is my final promise :)
                Imagine this amount of atrophy around your spine!

                http://dermnetnz.org/dermal-infiltrative/lipodystrophy.html

              2. Harriet Hall says:

                Your comments are getting more and more incoherent and irrational. Now you offer a “promise” that consists only of a request to imagine something. You are wasting your time commenting here, because this is a science-based medicine site and you haven’t offered any credible scientific evidence to support your wild claims. All you have done is to serve as a bad example of non-science-based thinking, the antithesis of what this blog is about.

              3. windriven says:

                Top ten, asshole. Why do you keep snuffling around here like a dog at a meathouse if you aren’t prepared to back your fantasies with some objective data? I’ve asked you countless times.

                TOP TEN disease entities that have been mastered by acupuncture.

                Science based medicine has transformed the human condition in monumental ways and pushes back the edge of darkness a little more every day. Meanwhile you and your codelusionals keep trying to prove perpetual motion as if it was both novel and real. You reason like a 10 year old.

              4. WilliamLawrenceUtridge says:

                “Hopefully sterile” is hilarious coming from Steve, considering he doesn’t believe in cleaning the needling site. Unless there’s poop.

                So – breaking the skin for a recognized medical procedure, after the skin has been swabbed down with an antiseptic? Watch out for those abscesses!

                Breaking the skin for a procedure of questionable value, only sterilizing it if the person is covered in actual visible filth? That’s just fine, put down that alcohol! No need, because abscesses never form in or beneath the skin!

            2. MadisonMD says:

              Acrachoiditist

              Did you really graduate from medical school?

              1. windriven says:

                I wonder? I’ve got a crisp, clean twenty dollar bills that says he thinks the subarachnoid space is the area under a spider.

              2. MadisonMD says:

                Ha! And perhaps an arachoidontist puts braces on spider teeth.

              3. Stephen S. Rodrigues, MD says:

                Get ESI and you will find out what and where it is-meritorious one! :)

        2. windriven says:

          Oooo – still all talk and no evidence. The challenge is simple: top ten disease entities that acupuncture has mastered versus … almost any ten that real, science based medicine has mastered. Ten. Use the fingers on both hands. You can do it.

    3. Nashira says:

      “it’s not pain that’s the problem, as much as what pain represents.”

      Um. No. Seriously. I’m just somebody with trigeminal neuropathy but I can assure you that the pain is a gigantic problem when I am in the middle of an episode. Not what it represents, but the fact that it feels like somebody just dipped a portion of my face in lava. There is no reframe and no amount of mindfulness in the world that can help when that happens.

      1. mousethatroared says:

        Yeah, I suspect any reframing that would be helpful is not attempting to find a positive view of the worse pain you experience.

        I was reading the Chronic Pain Workbook* awhile back, which focuses on using CBT (and possibly mindfulness…not sure) to help manage pain. One thing they talk about is tracking flares to see if there is sort of timeframe that you can expect the flare to last at it’s highest severity. The idea being that a flare that has a predictable end is more tolerable than one that just feels like it will go on forever.

        I think the focus (of the book and many CBT programs) is more on managing how one uses non-flare times and increasing pain free or lower pain time through well planned exercise, rest and medication, as well as attempting to keeping a realistic perspective on the pain (avoiding catastrophic thinking, etc). Not, the questionable (in my mind) concept of pain relief through positive thinking.

        The other concept that jumped out at me from the book were that all chronic pain is NOT an equal balance of bio-psycho-social. Some chronic pain is primarily bio, some is more impacted by social conditions, etc. Decerning your individual balance can help manage the pain.

        And to be frank, much of the psycho-social stuff that adeimusfree discussed, is not actual pain. when one says, it’s not the pain that’s important, it’s the disability. People don’t have to be disabled. Well, great, but let’s be honest. That’s disability relieve, not pain relief.

        Just like all the positive psycho-social aspects of getting a tattoo don’t make the process pain free, they just make the pain tolerable.

        *Which I have not finished, so I’m not sure if I can recommend or not.

        1. Stephen S. Rodrigues, MD says:

          The fear, abandonment and insecurity that chronic pain can lead to will destroy a person’s will to live.

          To treat pain effective this must be addressed!

          1. windriven says:

            Time to represent, Rodrigues. You CAN do that can’t you? Top ten disease entities that acupuncture has mastered. Ought to be easy for you.

          2. mousethatroared says:

            @SSR In my case chronic pain leads to a fear of financial insecurity…one way I address this fears is by using my money wisely. Not throwing it away on quacks who make big promises but only deliver overpriced placebos, at best.

            The fact that one of these quacks would go out of their way to sow fear of effective medical treatment is not surprising. How else are you going to sell your ineffective therapies?

            1. Stephen S. Rodrigues, MD says:

              My patient state that the physical pain (24-7-365) and unknown overrides the finances. They feed off of each other.

              Find an alternative hands on provider and do yourself a favor.

              1. mousethatroared says:

                Actually, I went to a “alternative hands on provider” a few times and he made the pain I had worse and my pocket book slimmer….and assured me that his therapies were working.

                Not to mention that as an artist I know plenty of alternative type folks. I have yet to witnessed any miraculous or even slightly impressive results from alternative hands on therapies.

                Oh, now you’ll find some excuse for why that wasn’t the right provider or the right therapy, etc. Because with the “just try it” folks it’s always “no, no, just try something else” when the first or second, third, etc, alternative therapy doesn’t work.

        2. Nashira says:

          I’ve had my husband’s help identifying what can trigger flares for me and what the usual lengths are, by which I mean we figured out the triggers and *he* tracks it. Otherwise, if I see that it’s going to be OMFG COLD for a few days, I get anxious and grind my teeth and… trigger a flare, that the polar vortex makes worse. I am the best ever at self-defeating! So long as you can keep a rein on potential anxiety, it’s a very useful tool – one that I credit with helping me work full time. I do miss eating foods with texture when it’s real cold out, though. :P

          So I should amend my statement: even with severe pain, mindfulness and CBT can help, but it sometimes totally *is* the intensity of pain that drives you to seek help. We should focus both on relieving the pain and on relieving the disability as much as possible.

          1. mousethatroared says:

            I don’t understand it, but IME, the cold and nerves just don’t mix. The radiculopathy is aggravated by the cold too. I couldn’t figured out if it’s because I’m tensing up due to the cold or it’s just the sensitive nerve reacting (like a bad tooth).

            As to the bio/psycho/social connection, I have this love/hate relationship with the topic, so I am inclined to ramble. Between, my mother’s cancer, my experience with infertility, the mystery possibly autoimmune symptoms and then the pain issues, (all things that some group of experts will tell you can be helped through mind/body techniques of some sort or another) I’ve come to see anyone who views psychological intervention as a fix for physical conditions with extreme skepticism, maybe bias. In my case they have not only been ineffective, but have been a real unproductive distraction. On the other hand, I appreciate what CBT has done for my mental health, so I think why not use it to cope with stressful conditions.

            Finding the distinction between reality and hype is an ungoing process.

            Agreed on the idea that working to alleviate pain AND disability are both important. I would add working to increase enjoyable activities. It seems when you are not well and struggling to keep up with your obligations, the first thing to fall by the wayside is the things you enjoy. That can’t be good.

      2. Stephen S. Rodrigues, MD says:

        A lot of in the TN support family disavow any therapy that is over 20 yrs old!
        Why?
        Dogmatic assertion that modern medicine will find a fix!
        And
        Disrespect for all the pioneer of low tech hands on therapy.

        The result. A lot of miserable suffering members who are funneled into research and dead end studies. De Facto executioners.

        1. windriven says:

          Still talking idle sh|t and still no top ten disease entities that acupuncture has mastered. Your whole schtick is suckering people. When it comes down to crunch time – you’ve got nuthin’.

        2. Nashira says:

          Actually, I’m quite pleased with the marvels of modern technology, with regards to my condition. What you recommend would turn me into a miserable, unemployed, very depressed ball of pain again. What my doctor recommends makes it not quite a non-issue, but close enough for government work. I’m gonna have to take “actual effect, as evidenced based as we can get it” treatment over whatever you pull out of your fearmongering, dishonest, predatory posterior.

          1. mousethatroared says:

            “I’m gonna have to take “actual effect, as evidenced based as we can get it” treatment over whatever you pull out of your fearmongering, dishonest, predatory posterior.”

            Yeah, What she said.

            Why can’t I come up with lines like this?

    4. Stephen S. Rodrigues, MD says:

      Pain is personal and completely invisible and as a result patients suffer because a provider will not believe them and discount their plight — all because the providers have been programed to believe the material scientific dogma of modern medicine. AND blame the patients if they don’t get fixed my modern medicine which is infallible as per SBM.

      It is easy for a provider to discount a person’s pain. If pain was like a cancer easily seen under the microscope lawsuits would be the impetus to begin to use all of our old pseudo-scientific tools to help in any way possible. OH … who is going to pay??!! If we pay for a joint replacement that fail because they are unnecessary who not pay for voodoo that may work!!

      YES, so called Rodrigues-Voodoo may work in the proper hands, oh no medical degree needed just a few hours in Voodoo school!! :)

      1. windriven says:

        Top ten disease entities that your quackery has mastered, please. No more jawboning. Let’s have some real for a change.

      2. WilliamLawrenceUtridge says:

        Pain is personal and completely invisible and as a result patients suffer because a provider will not believe them and discount their plight — all because the providers have been programed to believe the material scientific dogma of modern medicine.

        Sure…that’s why one of the first questions doctors don’t ask is “where does it hurt”, and the second isn’t “what is your pain level on a scale of one to ten”, and visual-analogue scales for pain don’t exist. And it is modern medicine that is dogmatic, not the CAM practitioner who insists on misrepresenting it. It’s like reading intellectual santorum.

        Idiot.

  10. Hey if you can’t define a word please don’t embarrass yourself using it like you know!!!
    No one here can define Acupuncture so it would be inane to attempt to disparage it.

    The study was designed around flawed definitions of pain, how opiates affects pain, metabolism, moods and emotions(as in bound/withdrawal pain) and incomplete pain therapy.

    “It often… “alternative” medicine is to blur the lines of cause and effect, to exploit non-specific effects in order to promote a useless but profitable ritual (acupuncture comes to mind).”

    Your bias towards alternatives is obvious which makes your conclusions invalid and unreliable.

    “ ….properly replicated.”
    This is non-existent in medicine which is an ongoing clinical drug data collection after a drug has been approved.

    “The one discouraging result is that reduction in opiate overuse was not sustained. One rule of thumb in pain research is that what patients do is likely more significant than what they say. If they report less pain but use the same amount of pain medication, their report is likely biased.”

    These are issues related to a pain study; What is pain? Most studies do not take into considerate of the hourly or daily variability and personal aspects of pain. Pain is an enigma and can’t really be quantitated like a BP measurement, which can invalidate most studies.

    I am not sure everyone is on the same page as to the understanding of the placebo effects in chronic pain research. What is innate healing, placebo and or therapy? Difficult studying human account of pain, human nature and the human mind.

    1. windriven says:

      Where are your top 10 Steve? Jabber, jabber, jabber but when it comes time to show your cards you’ve got nothing but more jabber, jabber, jabber. Typical con man behavior.

    2. WilliamLawrenceUtridge says:

      Acupuncture, noun – 1) Whatever Stephen Rodrigues, ND, wants it to be

      2) Definitely not what was tested if the results are negative.

      Steve, you really are an arrogant twit. You claim to know more than everyone, claim to have better definitions than everyone, claim to understand pain better than everyone. But when it comes right down to it – all you want to do is justify what you are already doing. You don’t care what the evidence base is, unless it supports what you are already doing. You’ll babble specious nonsense about innate healing and the human mind, but when it comes down to it – you don’t really care as long as you don’t have to learn anything new or challenge your preconceptions.

      Sad little arrogant man.

      1. Adam Rufa says:

        I was not aware that the definition of Acupuncture is so difficult to understand. How would you define it Steve?

        “The study was designed around flawed definitions of pain”
        I am not sure what that means, could you explain this in more detail. Do you not agree with the definition of pain endorsed by International Association for the Study of Pain?

        “Your bias towards alternatives is obvious which makes your conclusions invalid and unreliable.”

        Steve this seems like faulty logic to me. Wouldn’t you agree that someone could be biased yet still come to a valid conclusion? Their process of reasoning may be unreliable but even unreliable methods can lead to correct conclusions. So the accuracy of a conclusion is irrespective of the bias or process used to make the conclusion.

        1. windriven says:

          “How would you define it Steve?”

          I’m sure he would define it it as The Singing Styli of Salvation!

          His salvation of course. I imagine he’s scuttling around with this nonsense because working as a real physician is … Haaaarrrrrdddd and likely beyond his skill set.

          A physician friend noted to me that once you’ve gotten out of med school, everybody’s got an MD. Might have been first in the class, might have been last. You can’t tell by the two letters.

          I’m guessing our buddy wasn’t first.

          1. Stephen S. Rodrigues, MD says:

            Attack the person strategy, weak!
            I know what it is or is not!
            Besides why don’t you’ll get together and make up one — It would be more fun to critique whatever your definitions maybe! :)
            Clue … it is not what you think it is!!

            Oh while you are at it define “pain” too.

            1. windriven says:

              More sad slobber from Rodrigues. I wouldn’t have to attack the person if the person had enough guts to stand up for what he talks about. Top ten. Let’s go big mouth.

            2. Adam Rufa says:

              I would define pain as “An unpleasant sensory and emotional experience associated with actual or potential tissue damage”.

              1. Stephen S. Rodrigues, MD says:

                Good definition.

            3. WilliamLawrenceUtridge says:

              Attack the person strategy, weak!

              That’s hilarious considering how many times you have asked myself, windriven or other commentors for their qualifications rather than addressing their points.

  11. Joel Dykstra PT says:

    “Physiologically pain is produced by tissue damage or pathology provoking pain signals in sensing nerves (nociceptive pain). This type of pain serves a protective purpose, and does not last beyond the pathology itself.”

    If I, too, may be picky about a definition…

    Pain is produced by actual or “potential” tissue damage.

    That is what makes it an effective protective system. We can act to reduce the noxious stimulus prior to it actually causing harm.

    On a related note, we need to help our chronic pain patients understand that the pain they feel (removed from an actual harmful stimulus) does not equate to tissue harm occuring. This is where the pain is no longer serving its protective purpose. This can be as difficult for clinicians to believe as the patient if they are too biomedically oriented.

    1. Stephen S. Rodrigues, MD says:

      What happens when the “pain signal” gets corrupted and is blaring like the dickens when there is no detectable damage or irritant the modern medicine can detect?!!

      oh what about phantom pain?

      There is an answer.

      1. windriven says:

        We’re all tired of your prattle. Time to put up. Top ten disease entities that acupuncture has mastered. Big man. Big mouth. Now it is time for Big Evidence.

      2. MadisonMD says:

        Yes! SSR: top ten. To make it still easier– that’s how many fingers you have.

        1. Scottynuke says:

          “That’s how many fingers you have.”

          Assumes facts not in evidence — for all we know SSR could be polydactyl or be a double amputee who uses his feet to insert the useless needles.

          But yes, SSR — your continuing inability/unwillingness/fear of listing the top 10 conditions acupuncture has solved is duly noted by the semi-lurking community.

          1. Stephen S. Rodrigues, MD says:

            See below.

  12. Jay Lee says:

    When studies report greater effects but then provide p-values instead of effect sizes, other mistakes were likely made.

  13. Osman says:

    I also Think that when studies report greater effects but then provide p-values instead of effect sizes, other mistakes were likely made to easy us.

  14. daedalus2u says:

    There are very good physiological reasons to expect mindfulness meditation to improve pain relief. The placebo effect is mediated through nitric oxide, and is what switches physiology from the “fight-or-flight” state (where healing pathways are turned off) back to the state at rest where healing pathways are turned on.

    http://daedalus2u.blogspot.com/2007/04/placebo-and-nocebo-effects.html

    Mindfulness is one of the very few methods that can be used to raise systemic NO/NOx status.

    I cite a number of studies that show mindfulness meditation is associated with higher NO/NOx status, and that is is also associated with reduced incidence of disorders characterized by low NO/NOx.

    It is the common pathways mediated through NO signaling that cause “stress” to exacerbate things like chronic pain.

    Pain is the nervous system signaling something. How that signaling is interpreted depends on the physiological state of the organism. If you are still in fight-or-flight, then you still need to worry about damage to your body. If you have transitioned out of fight-or-flight, then you can relax and let your body divert resources to healing.

    I suspect that one of the reasons that opiates are so effective is because they mimic endorphins. Endorphins are molecules released during fight-or-flight so that the pain signals that are being received can be noted and ignored while more important things are being done (as in continuing your escape from the bear chasing you). They let you dissociate the feelings of pain from the things you need to do to survive. Of course this can only be a very short-term solution, so the automatic gain control has to eliminate this effect which is why tolerance develops.

  15. Marion says:

    Thank you, thank you, THANK YOU ALL for bringing up that HORROR of 21st century medical waiting rooms: THE GODDAMNED TELEVISION SET!!

    I remember the 1970s when magazines were available as a distraction.

    But, now apparently it is a LEGALLY MEDICALLY NECESSARY REQUIREMENT (must be some obscure law of physiology of which I’ve never heard) that a LOUD BLARING TV set to mainstream/lamestream (i.e. rightwing conservative) television be FORCED upon patients in every waiting room of every hospital, doctor, dentist, rehab center, etc.
    Without a single exception (except for my beloved rheumatologist) they force “got” to force this crap onto patients. And the channel is ALWAYS turned to ABC or FOX.

    I am deliberately choosing to ignore my stupid gastroenterologists’ numerous phone calls & written pleas that I get another colonoscopy this year, because they have a damned tv in the waiting room. I already had one one year ago. I don’t need one for another 5 years, and I cannot afford one for another 5 years (if ever).

    If my condition were actually really serious (I’ve had flaming colitis for over 13 years now) or the threat or risk of colon cancer were something important, the doctor would
    1. get rid of that tv
    2. know the true total costs of a procedure he allegedly performs thousands of times a year (for me last year, it was $9000 – all bills. I paid $550. Still too much for me to pay each year.)

  16. Stephen S. Rodrigues, MD says:

    It is the only therapy I would recommend for pain conundrums. The most common problems I see are mostly failed traditional surgeries;

    ALL get better enough to have a better quality of life about >25-100% improvement.
    Failed facial pain as in TN, ON, Cervical, Thoracic outlet, shoulders, lower back, hips, knees and wrist and toes.

    Migraines, Tension Headaches, Cluster headaches, TMJ, Vertigo, IBS, Chronic pelvic pain, RLS and most diabetic neuropathies >50-100% improvements.

    Vital! Once the myofascial “pain” metastasis into the paraspinal muscles and small rotators of the vertebra and/or the pain has altered the cellular structures of the area ie RSD/CRPS … all bets are off and I would only expect more than 25% improvement in pain.

    Vital! This is why therapy should be implement early in a pain cycle or we as a medical community, we are locking these patients into a medieval prison.

    1. MadisonMD says:

      Failed facial pain as in TN, ON, Cervical, Thoracic outlet, shoulders, lower back, hips, knees and wrist and toes… Migraines, Tension Headaches, Cluster headaches, TMJ, Vertigo, IBS, Chronic pelvic pain, RLS and most diabetic neuropathies >50-100% improvements.

      Is this your “top ten,” SSR? Let me help you by enumerating the actual medical diagnoses (Ignoring nonspecific pain that you list*)
      [1] Trigeminal neuralgia
      [2] Thoracic outlet syndrome
      [3] Migraine headache
      [4] Tension headache
      [5] Cluster headache
      [6] Temporomandibular joint disorder
      [7] Vertigo
      [8] Irritable Bowel Syndrome
      [9] Restless leg syndrome
      [10] Diabetic neuropathy

      OK, Windriven, this is as close as you can hope to get from SSR. All are subjective and, not surprisingly, any could respond to placebo. There is no evidence that acupuncture does anything beyond placebo for any of them [Prove me wrong with a citation SSR-- please!]. Time to spring your top ten, Windriven. Then we can compare.

      ————————–
      *To understand why a diagnosis is needed for pain imagine:
      pt: “Doctor my wrist hurts”
      ND: “Try acupuncture”
      pt: “But I fell on it and the bone is sticking out.”
      or
      pt: “Doctor my back hurts”
      ND: “Try acupuncture”
      pt: “Do you think it might be related to my metastatic prostate cancer?”
      or
      pt: “Doctor, I have pain in my pelvis”
      ND: “Try acupuncture”
      pt: “I did a self pregnancy test– positive– do you think it is ectopic?”

      1. windriven says:

        Well Madison, it will take me a little time to scrounge around for that. Ten is a mighty big number. Rodrigues has the advantage because acupuncture has been around for so very long. But I’ll do my best to think of something.

        1. Smallpox. Gone in the wild. It exists only as a laboratory curiosity and potential biological weapon.

        2. Polio. Afflicted presidents and peasants. Children spent their youth in iron lungs. Polio persists … barely. And only in the most reactionary backwaters where medicine is an affront to god or to the local strongman.

        3. Pertussis. A horrific disease that snatches breath and life before that life has even really started. Pertussis occasionally rears its ugly head in communities where scientific medicine is eschewed in favor of maintaining the purity of children’s precious bodily fluids.

        4. Leukemia. The first of the cancers that scientific medicine has really kicked the bejesus out of. Once a death sentence, most leukemias now see survival rates in the 60-80% range – and these get better all the time.

        5. Breast cancer. During my lifetime breast cancer often meant horrifically disfiguring surgery and often an early death. Survival rates at Stage III are now 72% and climbing. Caught early enough the survival rate is nearly 100%. We can save the tatas and the tata life support system. Nice.

        6. AIDS. It isn’t a cure. But it isn’t a short slide to the cold hole either. HAART has transformed the lives of those infected with HIV. Death sentence to manageable condition in what, 30 years?

        7. Diabetes mellitus. Another disease that affects millions. Treatment has improved continuously with a variety of synthetic insulin analogs now available.

        8. Tuberculosis. The grim reaper’s best friend. Still endemic in some parts of the world, tuberculosis could have been all but eliminated had there been sufficient political will.

        9. Angioplasty. I couldn’t hazard a guess as to how many lives have been saved and how many more dramatically improved with this family of interventions. Just the number of CABGs avoided is huge.

        10. Organ transplantation. Kidneys. Livers. Corneas. Hearts. Lungs. The occasional face. I didn’t want to finish this list without a nod to major surgery and organ transplantation is perhaps its apotheosis.

        Sadly, I wasn’t able to get to either diagnostic or interventional radiology other than angioplasty, Or to neonatology. Or to fertility. Or to anesthesiology. And I didn’t get to exercise physiology or nutrition.

        No needles involved other than hypodermic syringes. Tens of millions of lives saved. Many, many millions more transformed. Just from these 10. Not one effing one from an acupuncturist, naturopath, chiropractor, or homeopath.

        Crap! I had intended to put blood transfusion on that list.

        11. Blood transfusions. Trauma. Surgery. Some cancer treatments. But we had to learn why different people’s blood was sometimes different. We had to learn how to type and match. Science. Not candle smoke and herbs and needles in your ear lobes.

        I’m sorry SSR, I’ve gotten off on a tangent. Tell me again about those magic needles again…

        The point of this exercise isn’t that chronic, difficult to treat, pain isn’t important. It is. The point is that the answer won’t be found on a map of acupuncture meridians. The scientific method is the answer. All of the leaps that I mentioned came from the application of science. If you want to help people and if chronic pain is your passion, get some science education and get to work.

        1. Stephen S. Rodrigues, MD says:

          You’ve made a few sophomoric errors as an investigator, you’ve assumed that I ignore the obvious benefits of modern medicine.

          I see the benefits in all aspects of medicine and the healing arts. That is why my patients are grateful.

          If this health care system was truly a capitalist system, patients would be able to sue for a failed procedure, poor outcomes or harm (made to go the hospital for a drug reaction). That would really be the method to employ in an attempt to find what works. I see the failures in the flawed system and wonder why you guys don’t care about patients well being!!

          1. weing says:

            “If this health care system was truly a capitalist system, patients would be able to sue for a failed procedure, poor outcomes or harm (made to go the hospital for a drug reaction).”
            So you claim a 100% success rate?

          2. mousethatroared says:

            SSR “I see the benefits in all aspects of medicine and the healing arts. That is why my patients are grateful.”

            Your patient ratings on healthgrades.com are below the national average for your specialty and there appear to be numerous doctors in your area that have much higher ratings. This is not to mention the patients on other sites that called you shady, said you weren’t worth the money and that you billed insurance for procedures you didn’t preform.

            Not that I put huge stock in online patient ratings, various things can skew the results, there’s no verification of accusations, etc. But I wouldn’t draw attention to yours, If I were you.

      2. Stephen S. Rodrigues, MD says:

        Duh … I’ve been doing this for 3 decades and try not to be that stupid. I understand the situation and any wise provider would rule out such dangerous and deadly situations. OR they would be sued out of practice!

        Today a surgeon can claim to “fix” a disc or vertebra cardblanc with absolutely no oversight. (Except his word) As long as all the 3 boxes are checked off; 1. pain 2. MRI defect 3. a consent signed by the patient. Everyone is happy; the doctor, the anesthesiologist, the hospital, the hardware company, etc. No one really cares what happens to the person in this equation.

        YALL don’t give a hoot because you are “scientist” and researchers who only look at the necessity and worth of the care. If the scans are better or OK and the surgeon can not find a thing to fix, patient is just dumped. No recourse for the patients as long as all the boxes are checked.

        1. MadisonMD says:

          Duh … I’ve been doing this for 3 decades and try not to be that stupid. I understand the situation and any wise provider would rule out such dangerous and deadly situations…

          Glad to hear it. So you do, in fact, see value in Science-Based Medicine for deadly disease.

          …OR they would be sued out of practice!

          Would they? Perhaps. (The surgeons you deplore are not being sued.)

          Today a surgeon can claim to “fix” a disc or vertebra cardblanc with absolutely no oversight. (Except his word)

          Exactly, by golly, SSR! I agree with you 100%! This shouldn’t be done without some pretty damn good evidence it works!

          Two questions:
          1. Do you want to limit this requirement for evidence only to surgeons?
          2. If a surgeon told you about 10 people who felt better after back surgery, would you accept this as proof?

  17. Andrew says:

    Until we really start to understand the physiology of these chronic pain conditions and find objective markers, then the CAM style claims as well as lots of nonsense about the physiological effects of placebos will continue. Notice how the “evidence” of these are based entirely on self-report questionnaires. Some have claimed to have observed physiological change, but they are vague and non-specific and much more research is required.

    CAM and other alternative ideas sort of seeps in to the gaps of science and the only way to remove it is by making the underlying science much more comprehensive. Simply speaking louder about CAM not being “science based” (or “evidence based”) is not going to be effective.

  18. PMoran says:

    SAwyer: “The result of your approach is that even IF what you do has some benefit (which I vehemently disagree with), you are cursing the next generation of pain sufferers to the same crappy techniques we already use.”

    I am not sure what you mean by that sentence, but why would you vehemently disagree with patients deriving ANY benefits from Rodrigues care? Do you truly think that? If so, clarify how.

    I agree that Rodrigues will have an exaggerated sense of what he is achieving. but Steve Novella has just outlined many ways in which psychological and other non-specific influences may alter pain perception — “At every step in the process, pain intensity can be modulated“. These and other “incidental” influences within almost any medical interaction can plausibly also trigger changes in illness behaviour and in the ability to cope, just as CBT and support groups might.

    So, what gives?

    1. mousethatroared says:

      Since SSR appears to be actively discouraging effective treatment with misinformation and scare tactics (see his summary of corticosteroid injections/epidurals and surgery up thread) I am highly dubious that his patients experience a net gain in pain relief. I mean, there are probably people who made money with Bernie Madoff too, but…

      God forbid a patient with an undiagnosed serious illness in need of a knowledgable attentive physician walks through his door and put their trust in him.

      I understand that there might be some non-specific pain relief effects from non-active treatments, but you do need to balance that against someone who lives in pain for months or years because their accupunturist has lead them to be morbidly afraid of effective therapies that can help them.

      I hope you know, I don’t say this lightly, but the guy’s a leech, pmoran. I understand the point you are trying to make. but please don’t use SSR as an example without acknowledging the risks that associating with this kind predatory practitioner brings.

      1. mousethatroared says:

        And I still say if someone’s going to charge me a bunch of money to stick needles in me, I want them to throw some ink on there, so I can have something pretty to show for it.

        1. windriven says:

          So mouse, your avatar appears normally. Mine has morphed into a blueman silouette as has Andrey’s, Sawyer’s, and some others. What gives? My avatar works on other sites where I use my gmail login. Are you logging in using some other service?

          1. Andrey Pavlov says:

            An artifact of my utter laziness. LOL. My google sign in signs out periodically. The way I manage to browse comments these days is to go through my RSS reader and as I do, the ones that interest me I open in Chrome. After I have gone through them all I then go and look them over and respond. If I am signed out, it is the teensiest tiniest more hassle to sign in so I don’t. Sheer laziness is all.

      2. Sawyer says:

        I was about to write a response but you already nailed it in the first paragraph. Technically a fraction of his patients may derive some benefit, but this is a useless metric to me. What I care about is the net benefit. And this is more important when dealing with subjective measurements like pain, not less.

        I know Peter has heard this all before, but I think his obsession with crafting every single word in a discussion with people like SSR is a huge waste of time. We’re not trying to publish a freaking Nature paper here. Believe it or not, I actually did pause for several minutes on the word “some” when writing that post. I realized someone could step in and make a pedantic point about minor benefits, but I decided it was not worth changing it because the overall point was still very clear. If we include pages of caveats to every discussion of acupuncture it will only make the discussion worse, not better.

      3. PMoran says:

        You are not describing the medical reality, MTR.

        It is highly unlikely that SSR sees many patients who have not already tried some conventional care, or who would certainly have found that an adequate answer to their problems if they had.

        He is clearly using acupuncture for often difficult conditions where there will be little downside if the method does not work. And who is going to continue with it for “months or years” if it is not helping?

        The dangers you see may even be balanced out by him sparing some patients more invasive methods such as epidural injections or surgery, or the dangers of long-term opiates or NSAIDs, because the resort to those is typically driven by ongoing patient distress. Even just waiting a month or two longer during a program of acupuncture will alone predictably result in some spontaneous relief in some patients. This will be one of the factors giving SSR an inflated perception of his worth.

        The most important possible outcome in these exchanges is that the practitioners and their clients understand the medical limitations of the methods being employed. They will NEVER agree that they don’t help at all, so that this vital issue gets lost in the mutual exasperation of “it doesn’t help”/ it does”.

        I am sorry, but in my view these are ill-considered statements and not an accurate reflection of what our own science permits in any truly impartial appraisal. The public can understand that methods may “work” via psychology (suggestion etc) and other nurturing influences, so there is no need for such paternalistic over-simplifications.

        SSR seems to have some understanding of these limitations, somewhat surprisingly, judging from the list of conditions that he uses acupuncture for..

        1. mousethatroared says:

          pmoran – “It is highly unlikely that SSR sees many patients who have not already tried some conventional care, or who would certainly have found that an adequate answer to their problems if they had.’

          If you google his name, he’s advertising as a family doctor who treats mainstream illnesses such as thyroid, diabetes, etc and appears to bill standard health insurances. I don’t know were you got the impression that he only accept last resort patients. The patient reviews on http://www.vital.com seem to indicate that people think of him as a standard doctor, not as a last chance alternative/pain clinic.

          I’m not going to get into your “work” not “work” argument. I don’t feel like arguing semantics. I have dealt with enough unethical folks in my life to say SSR comments/tactics set of major alarm bells. If you want to send your relatives or friends to a similar doctor, I guess that’s your choice. I think it’s a serious mistake. I know, I wouldn’t.

          1. Stephen S. Rodrigues, MD says:

            Still trapped in the material, mechanical dogma. Before you guys evaluate another study related to pain and alternatives.

            You must define pain; Remember you can not see pain with a scanner, test for it or see it in the blood. It is personal to a particular case. Short-term pain is different than long-term pain.

            Acupuncture type variety and provider; all are not the same and all are user and patient dependant. It is not what your brain has imagined. It should not be used alone without a complete wellness package. Acupuncture is the tip of the iceberg of needle surgery and can be modified into the overall disciplines as in Prolo-Therapy, Biopuncture, some steroid injection, PRP injections and

            Don’t insult a person or patient with a head to head studies like with a chemical which would be invalid from the get-go.

        2. MadisonMD says:

          Peter,
          MTR is fully justified in calling SSR a leech. You want physicians to avoid paternalism. Well MTR is a patient, SSR is a physician and this is an example of his paternalism. This is exactly the behavior for which you impugn science-based providers–except his is not based on evidence. I suspect you missed this, because a consistent and honest acupuncture apologist like you would have to ding SSR on that one. You are after all, in favor, of honest communication between physicians and patients based on real assessments of interventions, no?

          The most important possible outcome in these exchanges is that the practitioners and their clients understand the medical limitations of the methods being employed.

          It is abundantly clear that SSR does not understand these limitations and so this most important possible outcome clearly cannot occur in his practice.

          It is highly unlikely that SSR sees many patients who have not already tried some conventional care, or who would certainly have found that an adequate answer to their problems if they had.

          Your assumption that patients who reach is office are adequately vetted through competent medical practitioners is just that– your assumption. Patients do not require a referral to see a botique practitioner like SSR for cash payment. SSR would have to tell us how patients are vetted to validate your assumption.

          1. Stephen S. Rodrigues, MD says:

            “competent medical practitioners” This is the issue!

            Without being able to offer a patient ALL possible therapeutic options in a clear unbiased, concise manner this would be mis-informed consent and thus malpractice. (not just the procedures sanctioned by the pro-profit, biased doctors who are the AMA)

            Actually malpractice would be rampant if not for the AMA and the government dictation what is valid and not valid. The few hundred failed cases would have a recourse. A proper law would allow us to find the truth.

            If the system was truly free and open, patients would have a choice to go to what works for them and the AMA would have some ‘splainin” to do.

            (this is for chronic pain and dysfunctions or conundrums) Excludes cancer, trauma, infectious disease, trauma and aneurysms.

        3. Andrey Pavlov says:

          @pmoran:

          And who is going to continue with it for “months or years” if it is not helping?

          This is a false notion you must disabuse yourself of. It is likely leading to a lot of our words with each other. It is extraordinarily well documented how people will continue with things for very extended periods of time with not only no help, but obvious signs of harm. You’ve seen this yourself with breast cancer patients who will let the tumor fester and rot and continue to use their bunk treatment claiming it is helping them.

          To even spuriously mention this as an argument is telling. This is precisely the same completely fallacious arguments everyone from the MD who dabbles in acupuncture to the quackiest of quacks will say. Why would people keep going back to them if their treatments didn’t help?

          Or are you trying to pull some double-meaning here and try to insinuate that the fact that the person is going is prima facie evidence that it is helping them, even if only in a completely deluded and purely subjective sense?

          Either way it is poor form.

          The dangers you see may even be balanced out by him sparing some patients more invasive methods such as epidural injections or surgery, or the dangers of long-term opiates or NSAIDs, because the resort to those is typically driven by ongoing patient distress.

          Seriously? Why are you so incredibly desperate to protect this individual who is either a complete troll or an obviously dangerous, deluded, and completely irrational individual?

          This will be one of the factors giving SSR an inflated perception of his worth.

          We understand the power of delusion, even self-delusion. We aren’t the ones making the argument I cited first.

          The most important possible outcome in these exchanges is that the practitioners and their clients understand the medical limitations of the methods being employed.

          And there is beyond ample evidence that SSR absolutely and unequivocally does not know these limitations.

        4. mousethatroared says:

          pmoran “And who is going to continue with it for “months or years” if it is not helping?”

          Well, If I believe that most surgeries for cervical disc disease are dangerous failures…as SSR implies and if I believe that epidural steroid injections will result in the tendons and ligaments spontaneously detaching from the bone, the vertebrae to slip with the possibility of paralysis as SSR says, than what choice would I have than to continue with ineffective treatment for months or years?

          As a side note, effective treatment for cervical radiculopathy actually takes months. It’s not like patients pop into the doctor after a couple days of pain in their arm and they get sent in for a MRI, then sent for epidural injections or surgery. No, the standard of care has graduated interventions to allow symptoms to resolve on their own or with PT, if possible.

          For me, it took 10 months from onset of daily pain that interfered with my activities, 4 month of daily (at least hourly) tingling and prickling in my thumb and index finger in addition to weakness in my affected arm to get diagnosed, go through less invasive interventions and receive a referral for an epidural to be recommended.

          Apparently, you think it would have been good for me to be lied to by SSR so that I could try acupuncture (after the PT, neck brace at night and NSAIDS) and then be five times as terrified as I already was going into the epidural.

          Or don’t you think that SSR was lying about the epidural. Because either MY doctors were lying or SSR was lying. Which is it pmoran?

        5. mousethatroared says:

          pmoran “The dangers you see may even be balanced out by him sparing some patients more invasive methods such as epidural injections or surgery, or the dangers of long-term opiates or NSAIDs, because the resort to those is typically driven by ongoing patient distress.”

          pmoran You have failed to point of the theraputic benefits of epidural injection OR surgery…they are complex interventions, aren’t they?

          Also – you have failed to point out the therapeutic benefits of long-term opiates. I can give you lots of anecdotal evidence of benefits of heroin. Many artists find that it not only helps greatly with pain relief, but encourages them to relax and boosts their creativity. Will Burroughs was a strong proponent of heroin and not only did he live to a ripe old age, but he was a prolific writer. How can you talk about the dangers of long term opiate use without acknowledging the benefit that William S. Burroughs experienced?

          You have also failed to acknowledge the therapeutic benefits of NSAIDS. How can you not take the time to address this?

          pmoran. How can I trust you AT ALL unless you consistently (in each post you write) acknowledge the therapeutic benefits of epidurals, surgery, heroin use and NSAIDS along side those of acupuncture?

          Although, gosh, it would be nice if we could…somehow, figure out which of these interventions is superior, in terms of efficiency and safety.

          No, No! that’s not important. What’s important that we acknowledge the therapeutic benefit of each interventions so as not discourage dialogue.

          1. Andrey Pavlov says:

            How can you talk about the dangers of long term opiate use without acknowledging the benefit that William S. Burroughs experienced?…….

            Bazinga!

      4. Stephen S. Rodrigues, MD says:

        Informed consent with all the data is frightening. Especially when is it you under the knife.

        1. MadisonMD says:

          So, SSR, you are against providing informed consent?

    2. windriven says:

      “why would you vehemently disagree with patients deriving ANY benefits from Rodrigues care? Do you truly think that? If so, clarify how.”

      So … if any patient anywhere claims benefit we should embrace it? If not, what is it about acupuncture that sets it apart for special embrace? Prehistoric, to say nothing of prescientific, shamanism endured because some believed they derived some benefit from it. But does that mean we should find room in the armamentarium for chicken bone rattles and smoldering goat dung?

      Science based medicine has clawed beyond this at no small cost. The current post-modernist willingness to, if not embrace, at least smile and accept any rank bull-feces doesn’t make it right, smart, or cloak it with effectiveness. When did it become acceptable to call baloney Beef Wellington? When did it become acceptable for scientists to do that?

      It is worth studying placebo and how and why people impute clinical value to it. It is not valuable to pretend that placebo therapies are something else, much less allow quacks and shysters to build a faux-clinical practice around the mythology.

      But that’s just me.

      1. Stephen S. Rodrigues, MD says:

        This is not so much about Acupuncture … please DO NOT FOCUS ON ACUPUNCTURE!!!!! but about all the therapies that use a needle. See my prior post.

        They are valid and vetted … this is the truth and it will not go away!!

        I have ideas that could help one understand but one has to have an open mind.

        1. MadisonMD says:

          This is not so much about Acupuncture…but about all the therapies that use a needle.

          Epidural injections uses a needle.
          Vaccines use a needle.
          Surgery often uses a needle.
          Placing an IV line for saline infusion uses a needle.

          Is it your claim that it is the needle per se that has the therapeutic effect for these interventions?

          1. MadisonMD says:

            blockquote fail

          2. Stephen S. Rodrigues, MD says:

            Please … get you head out of your stratosphere and do some research!

            Use your God given brain and common sense.

            I’m leaving if you guys don’t ask the correct questions or don’t do your home work!

            1. MadisonMD says:

              I was just trying to figure out what you were trying to say. But you’re point is taken… why bother?

            2. WilliamLawrenceUtridge says:

              I’m leaving if you guys don’t ask the correct questions or don’t do your home work!

              I’m so, so sad that this didn’t pan out.

              Steve, don’t you see what bullshit this is? You’re like a sitcom girlfriend – unless we ask the right questions, we’re a bad boyfriend.

              Well perhaps if you explained the issues clearly and comprehensibly, we wouldn’t have to pussyfoot around and “ask the wrong questions”. I mean seriously, what kind of immature bullshit are you dicking around with? Do your customers only get treatment if they manage to correctly guess what you think their diagnosis is? Is there some reason you can’t be explicit about your points, other than the fact that it would illustrate your complete lack of credibility?

              Jesus, it’s like being in high school. We might be able to use our brains and common sense if we didn’t have to play mind reader. Or perhaps the problem is you are unable to clearly articulate the theory that guides your practice?

    3. Andrey Pavlov says:

      Hey, I’m sure that Stalin loved his mother and gave a child a piece of candy once in his life too.

      I’m sure that Graeme Reeves and Jayant Patel had some patients who derived some benefit from them as well.

      1. windriven says:

        I don’t know about Stalin, Andrey. I read a bio of him some years ago and I remember him coming off as pretty much loathsome from his teen years on. One unforgettable vignette had him, as a teen or young man on an outing with friends, seeing a calf stranded on high ground after water had risen, bleating. Stalin swam over and broke the calf’s leg (or legs the details are lost in the mists of my mind). Presumably to give it something to bleat about. Jesus.

        1. Andrey Pavlov says:

          @windriven:

          Yes, I know he was indeed pretty darned loathsome. Yet for some reason my grandmother – who won medals of valor in the Stalingrade blockade of WW2 – went to her death singing his praises and loving him. So at least there I’ve got anecdotal proof that he did something of benefit for at least one other person.

          The point is that just as it is impossible to prove a negative, it is also impossible to demonstrate that literally every aspect of someone’s life provided no benefit whatsoever, even merely perceived benefit, to at least someone else’s life. Which is why Peter’s comment is an abysmally low standard not even worth mentioning. It is the type of stupidly pedantic point that I make to my fiance just to get her goat. It can have no legitimate point whatsoever.

    4. Harriet Hall says:

      “just as CBT and support groups might”
      Yes, and also simply listening to the patient, offering sympathy, and maybe a good massage.
      The point is, those routes will make the patient feel better without making false promises or misrepresenting the scientific evidence, and they don’t penetrate the skin.

  19. PMoran says:

    “Your assumption that patients who reach is office are adequately vetted through competent medical practitioners is just that– your assumption.”

    If this MD is not himself adequately vetting patients and seeking appropriate investigations and consultations, then that is a problem for his medical board.

    My “assumption” is true in general. There are ample studies showing that within Western countries only a tiny percentage of the population uses CAM exclusively. Even fewer, I suspect, would initially consult an acupuncturist or TCM practitioner for a severe, new, undiagnosed pain or not seek other opinions if one was not relieved by an initial period of care.

    I am being “rebutted” with fanciful notions as to how people might behave whereas the studies show that CAM users are mostly more sensible than sceptics like to imagine or tend to preferentially encounter in their sceptical activities. Yes, there are some kooks who will go to extraordinary lengths, but they are beyond reach, providing no reliable basis for policy and certainly no excuse for distortions of the truth,

    I am not here defending everything that SSR says — as I said it is “surprising” (considering some of his other views) that he does seem to mainly use acupuncture for painful conditions where studies suggest this kind of intervention can produce reported benefits — simply not in the way he believes.

    There is no good counterargument to the making of inaccurate statements, that we know are inaccurate and which are known to cause dialogue to break down. That is before we even start ask questions as to where our duty of care extends in some of the more tricky aspects of medicine. I have thought some of that through, but it is a work in progress.

    1. mousethatroared says:

      @pmoran – as far as I can see, here you failed to acknowledge the therapeutic benefits of not adequately vetting patients, using CAM exclusively, undiagnosed pain, kooks going to extraordinary lengths or in people making inaccurate statements.

      I can easily think of therapeutic benefit to each. I mean, sure, not adequately vetting patients may seem bad, but OUR tendency to attack every SEEMINGLY bad habit discourages an open dialogue with doctor who want to explore the options of treating breast lumps with salve* and the patients who believe them.

      Damn – I forgot to point out the therapeutic benefits of treating breast lumps with salve. So as not to be inaccurate.

      For my grandmother, the benefits were 1.)A feeling of relief, that the painful lump in her breast could be addressed with a salve rather than the dreaded mastectomy and chreamotherapy* 2)Avoiding the removal of her breast and radiation for a year 3)Slightly less money from her social security check being wasted on things like…oh well, she didn’t have hardly any disposable income, so she probably couldn’t buy the pillowcases and embroidery thread that she enjoyed….but ultimately that might have had a therapeutic benefit on her hands! There you go, she may have suffered less hand pain because her “doctor” sold her a salve for her breast lump rather than sending her in for a mammogram.

      Does that work better for you?

      *My grandmother, being elderly and not very well educated had a tendency to misspeak words…but in an oddly appropriate way. ;)

    2. Stephen S. Rodrigues, MD says:

      I don’t need your defense … but thanks for thinking out of the box.

  20. MadisonMD says:

    If this MD is not himself adequately vetting patients and seeking appropriate investigations and consultations, then that is a problem for his medical board.

    True. And we are talking about the Texas Medical Board here– we know how effective it is.

    My “assumption” is true in general. There are ample studies showing that within Western countries only a tiny percentage of the population uses CAM exclusively.

    So now you make another very bad assumption– viz. the population of patients that go to SSR’s clinic are a representative sample of the entire population of patients in Western countries. That just doesn’t seem reasonable.

    I really have a difficult time parsing your other statements to pull out a salient point. For example, I cannot understand who you think is making an inaccurate statement or what exactly you are thinking through. I suppose you are showing us your thoughtfulness and judiciousness–perhaps you are more thoughtful and judicious than I am–but the meaning and purpose of the text is opaque to this reader.

  21. mousethatroared says:

    Sawyer – sorry to jump in here, hope I’m not stealing your thunder.

    pmoran – “If this MD is not himself adequately vetting patients and seeking appropriate investigations and consultations, then that is a problem for his medical board.”

    Are you saying that as long as a doctor has his license he is above reproach? That’s a bit of a catch 22, isn’t it? – can’t complain about a doctor with a license, medical board won’t sanction a doctor without people’s complaints.

    Nope, I’m not convinced. I think I’ll just complain when I think someone’s out of line and if that offends folks, so be it.

    pmoran “My “assumption” is true in general. There are ample studies showing that within Western countries only a tiny percentage of the population uses CAM exclusively. Even fewer, I suspect, would initially consult an acupuncturist or TCM practitioner for a severe, new, undiagnosed pain or not seek other opinions if one was not relieved by an initial period of care.”

    Except there’s no reason to believe that Sawyer was speaking generally – about CAM in generally or about people who are using CAM exclusively. He was speaking directly to SSR about HIS approach and “pain suffers”.

    Sawyer to SSR “The result of your approach is that even IF what you do has some benefit (which I vehemently disagree with), you are cursing the next generation of pain sufferers to the same crappy techniques we already use.”

    So if you are against inaccurate statements, you should stick to the fact that Sawyer was talking about SSR’s approach, not some generalized survey of CAM doctors, acupuncturists, etc.

    “I am being “rebutted” with fanciful notions as to how people might behave whereas the studies show that CAM users are mostly more sensible than sceptics like to imagine or tend to preferentially encounter in their sceptical activities. ”

    What I’m hearing is, you know that SSR’s statements are untrue, but you think most patients will see that he’s lying (or delusional). If they don’t, probably those patients are kooks and want to believe him, so let’s not upset patients (like myself) by pointing out his inaccurate statements.

    Same thing should go for car repair. Your mechanic tells you that you’ve blown a piston and that he should rebuild your engine for $4000. Your friend (a car enthusiast) thinks it’s more financially appropriate, considering the worth of your car, to put in a used engine for half the cost. But, clearly he shouldn’t patronize you by giving you this information. He should be “accurate” and say “yes, the rebuilt engine will work.” He should assume that you already know that the mechanic is taking you for a ride and if you choose to listen to the mechanic, it must be because you are a kook who is unwilling to listen to reason.

    Only, to be an correct parallel, your mechanic should tell you that a used engine will melt in your car and possibly explode.

    Man, I am so glad that the guys on Car Talk don’t take your approach.

    1. Sawyer says:

      Don’t worry, you’re not stealing my thunder. It would take me pages to explain exactly why I don’t agree with Pmoran’s interpretation and I just don’t have the patience to do so. SSR drained it away long ago.

      1. Stephen S. Rodrigues, MD says:

        I drained it away :)

  22. PMoran says:

    It’s not so hard, folks. People with weird ideas can almost certainly nevertheless help some patients, those with conditions that are responsive to psychological and non-specific influences. There is no logical reason why that should not be so and it is entirely consistent with our evidence base.

    They may even do good in some ways, but harm in others. Moreover, being wrong about some matters does not make them wrong on everything, notwithstanding a very common way of evading serious consideration of other viewpoints in sceptical discussions. Even on SBM at least as much time is spent rummaging through past writings and scrutinising web sites for anything that indicates heretical positions on medical matters as in making sure that “opposing” positions are fully understood.

    Even Steve agrees with the potential of such influences. He is only able to describe acupuncture as “unnecessary”, “useless”, and “profitable” (i.e. presumed scam) by applying an in-house definition of it, and also a very broad “operational” definition of placebo.

    These reflect the legitimate preoccupation of mainstream medicine and its science with methods having more clear-cut, intrinsic physiological or therapeutic activity.

    But they also have the convenient effect of precluding in advance of any discussion all the ways in which complex interventions like acupuncture may quite reasonably be expected to have some therapeutic benefits, as applied and understood in the real world. This is genuinely ivory tower stuff!

    Where I am heading, for those who have not followed my drift over some years, is that we might do more good overall concentrating on the very real dangers of CAM, and on cleaning up the mainstream’s own act, and certain aspects of our rhetoric, rather than attacking what will never ever be a very science-dependent human activity with scientific precepts.

    Medical choices have little directly to do with science. They mainly reflect where people are prepared to invest their trust when under medical stress.

    .

    1. windriven says:

      “Medical choices have little directly to do with science. They mainly reflect where people are prepared to invest their trust when under medical stress.”

      [W]here people are prepared to invest their trust has everything to do with science. It is why, even when I think we are blasting gnats with bazookas, I’ve decided to stick with that program. Shruggy thinking is just 17 micrometers from batshit quackery, today it is supplements, tomorrow oscillococcinum, a week later it is coffee enemas and ear candling.

    2. Andrey Pavlov says:

      I’ve been refraining because it is been a bit of schadenfreude on my part to watch Mouse take you to task, particularly after trying to bend her words to support your position in the past. And she (and Sawyer) have been doing an admirable job. But…. I couldn’t resist just a bit:

      He is only able to describe acupuncture as “unnecessary”, “useless”, and “profitable” (i.e. presumed scam) by applying an in-house definition of it

      No. This is incorrect. Blatantly, clearly, unequivocally correct. And this has been pointed out to you numerous times by myself, Dr. Novella, and others. The definition we employ is precisely both the accepted definition and the definition as used in the papers studying acupuncture themselves. Yet another notion you hold against evidence and should disabuse yourself of.

      and also a very broad “operational” definition of placebo.

      No. Again. I won’t waste my time explaining why on this one… again. But I won’t let it stand unopposed. You are incorrect here.

      But they also have the convenient effect of precluding in advance of any discussion all the ways in which complex interventions like acupuncture may quite reasonably be expected to have some therapeutic benefits, as applied and understood in the real world.

      Again, no. It has been discussed. And indeed, mostly dismissed. You’ve not offered evidence (because it doesn’t exist) of any sort of robust beneficial effect of acupuncture. Which is why the vast majority of data and meta-analyses conclude that acupuncture is not particularly effective for pain by any mechanism.

      Where I am heading, for those who have not followed my drift over some years, is that we might do more good overall concentrating on the very real dangers of CAM, and on cleaning up the mainstream’s own act, and certain aspects of our rhetoric, rather than attacking what will never ever be a very science-dependent human activity with scientific precepts

      And we once again head to where we know you’ve been wanting to go for ages – to complain that people other than you are writing about stuff that you don’t want them to write. And you get hurt when we call you a tone troll.

      So lets see, you’ve proffered up a few instances of blatantly false statements that have been addressed many times (and you say we are dogmatic!) and gone back to tone trolling the content of the blog. All while essentially accusing mouse – an artist, not a medical scientist – of “real ivory tower stuff.” You do realize you are arguing against her and not me, don’t you?

      1. mousethatroared says:

        Andrey to pmoran “So lets see, you’ve proffered up a few instances of blatantly false statements that have been addressed many times (and you say we are dogmatic!) and gone back to tone trolling the content of the blog. All while essentially accusing mouse – an artist, not a medical scientist – of “real ivory tower stuff.” You do realize you are arguing against her and not me, don’t you?

        I don’t even know how to respond to the ivory tower accusation. I could write out a long response*, but mostly it would amount to “Huh? Who me?”

        I will say though, I don’t think that pmoran is a tone troll. I would be less concerned if that was the case. He appears to basically disagree with my message that a medical doctor (SSR) who demonstrates a willingness to use deceptive scare tactics to discourage proven treatments so that he can sell his less effective treatments is a risky proposition.

        He is so caught up in the minutiae of the possibility of a ”all the ways in which complex interventions like acupuncture may quite reasonably be expected to have some therapeutic benefits, as applied and understood in the real world. ”
        That he can not acknowledge or attempt to address my concerns.

        I guess that pmoran must live in a different “real world” than me. Because in my real world people like a bit more concrete representation of a word like “therapeutic benefits” I doubt that most people would understand that he’s talking about things like being distracted or feeling comforted that someone is listening to you and attempting to address your symptoms.

        1. Andrey Pavlov says:

          @mouse:

          I could write out a long response*, but mostly it would amount to “Huh? Who me?”

          Peter seems to be taking any opportunity to simply repeat his standard party line regardless of whether it contextually makes sense or not. This is the second time I’ve called him out on it. He was obviously referring to folks like myself and Dr. Novella, even though neither of us were involved in the conversation. At least, that’s my take on it. I could be wrong and maybe he thinks you have been polluted by our “ivory tower SBM dogma” and are just parroting thoughts that are not your own.

          I will say though, I don’t think that pmoran is a tone troll

          He is not just a tone troll. But that is clearly what the last part of his response was – that his meaning, his intent, why he writes is because he think our collective focus at SBM is inappropriate.

          … we might do more good overall concentrating on the very real dangers of CAM, and on cleaning up the mainstream’s own act, and certain aspects of our rhetoric, rather than…

          That is simply a more rhetorically sophisticated way of saying, “You guys are not writing what I think you should be writing.”

          He appears to basically disagree with my message that a medical doctor (SSR) who demonstrates a willingness to use deceptive scare tactics to discourage proven treatments so that he can sell his less effective treatments is a risky proposition.

          It is, as best as I can see, a bit more subtle than that. He is not actually denying SSR is likely to cause harm to someone. He is trying to be a pointless pedant and point out that not everything about him is all bad and he must, in some way somehow, be helping some people, even if by just purely subjective means. A point nobody is disagreeing with or has even attempted to make. But is, indeed, real ivory tower stuff. While I acknowledge it to be the case, down here in the real world, that is hardly the relevant point.

          As you are saying, he is actually very likely to be clearly net harmful to people rather than actually helpful. It would take a real ivory tower attitude to blather on so much about the tiny and accidental benefit he brings to people rather than the real and tangible harms and concerning statements he makes. Of course, Peter retreats to this quasi-unassailable position where suddenly he is trying to make a sort of general comment about CAM practitioners in general, downplay the harm by calling them self selected, and then say his point is to focus on the aspect we so dogmatically gloss over in these discussions. And we loop right back to the beginning and his tone trollery about how we don’t write about what he thinks is important to write about.

          But of course, you knew that:

          He is so caught up in the minutiae of the possibility of a ”all the ways in which complex interventions like acupuncture may quite reasonably be expected to have some therapeutic benefits, as applied and understood in the real world. ”
          That he can not acknowledge or attempt to address my concerns

          Precisely.

          I guess that pmoran must live in a different “real world” than me. Because in my real world people like a bit more concrete representation of a word like “therapeutic benefits” I doubt that most people would understand that he’s talking about things like being distracted or feeling comforted that someone is listening to you and attempting to address your symptoms.

          An ivory tower, perhaps.

    3. MadisonMD says:

      Medical choices have little directly to do with science. They mainly reflect where people are prepared to invest their trust when under medical stress.

      Which is exactly why we need to license practitioners who practice medicine based on science– to avoid quacks who dupe the ill-informed ill.

      As for the rest of Peter’s points, I merely wish to agree that placebo effects are real, and disagree with all else. There is no point in writing more.

      1. mousethatroared says:

        Yes, I know that, pmoran has taught be that I should be more conscientious in pointing out the potential therapeutic benefits of complex interventions.

    4. mousethatroared says:

      @pmoran – as far as I can see (you go on at great length) you fail to acknowledge the therapeutic benefits of “evading serious consideration of other viewpoints”….although I know that you must be aware of them, since you have manage to evade seriously considering my viewpoint several times now.

      Then you say alot of stuff that I don’t really understand, either because it’s too technical, too immersed in the skeptic culture (which I’m not into) or too disorganized. I’m not sure. Before suggesting that my (?, Sawyers? someone else’s?) argument is Ivory Tower stuff.

      Oh sh*%t! Dude – you forgot to point out the therapeutic benefits of “Ivory Tower Stuff”.

      1. MadisonMD says:

        Then you say alot of stuff that I don’t really understand, either because it’s too technical, too immersed in the skeptic culture (which I’m not into) or too disorganized. I’m not sure. Before suggesting that my (?, Sawyers? someone else’s?) argument is Ivory Tower stuff.

        @MTR So you feel it too? Trying to argue with Peter is like wrestling a greased pig, but less fun.* The usual response you get is a statement of disagreement, a few opaque tangential statements, and an end with a flourish– a statement of uncertain opinion (but admission that he is still thinking it out), or perhaps a bland generality of dubious verity, but not easily falsifiable. There is only occasional grudging acknowledgement or engagement of the points you actually made.

        Incidentally, his ivory tower statement was part of the opaque tangent. It seems to have been directed at “mainstream medicine,” whomever that is, and not at you, MTR.

        *Yet I strongly suspect that, somewhere deep down, Peter’s heart in the right place.

        1. mousethatroared says:

          @MadisonMD – It’s not that I think pmoran is a bad person. It’s that I’m disappointed in the stance he is taking in this thread. And I’m not going to humor him just because his “heart is in the right place.” I don’t feel that I could do that without being dishonest and condescending. I just think he can do better. He could make his point AND condemn predetory doctors but I don’t think he is paying attention…I think he’s just writing on autopilot, without thinking of the people he’s talking to.

          When I was in college, my painting teacher once got angry with us for being uninspired and kicked a heavy metal stand across the room to encourage us to be more “present”. This is just my way of saying ‘wake up pmoran’. Maybe he’ll appreciate that it doesn’t include heavy metal objects flying about.

          I say a bit of internet sarcasm is a complex intervention that can have amazing therapeutic benefit and I will engage in it until…well probably I get bored or simmer down.

          1. MadisonMD says:

            Agreed!

    5. mousethatroared says:

      P.S.S. to pmoran

      Really? you have got to be kidding me! If you can not manage to address my concerns that SSR is using scare tactics based on misinformation* please be honest.

      Just say that your internal strategizing about how the skeptical world should communicate is far more pressing to you than any of my trivial thoughts on wanting to be treated honestly and ethically by the medical profession.

      *I’m sure using scare tactics based on misinformation has some therapeutic benefit, somewhere on some people, at some points in their lives.

      1. PMoran says:

        MTR: “”Really? you have got to be kidding me! If you can not manage to address my concerns that SSR is using scare tactics based on misinformation* please be honest.”

        MTR, I have warned SSR that his belief in the effectiveness of his acupuncture methods will be considerably exaggerated, that they don’t work in the way he thinks, and that they do not have assured general applicability, for example within a normal mainstream medical practice (or for sceptics like yourself).

        Why, then, would I resist criticising any false perceptions he has as to mainstream medical practice? I have not been reading everything he writes, I have been pursuing my own scientific interests, and surely some things could be left to be said by others. .

        1. mousethatroared says:

          I missed this yesterday,
          pmoran “Why, then, would I resist criticising any false perceptions he has as to mainstream medical practice? I have not been reading everything he writes, I have been pursuing my own scientific interests, and surely some things could be left to be said by others. .”

          No one expects you to read every post or be the one to criticize every misperception. But YOU asked why sawyer might deny SSR was offering benefit to patient. In answer, I specifically referred you to a series of posts upthread. MadisonMD, then linked you to those same comments. Those predatory comments by SSR were the whole point of my complaint.

          Clearly you were able to take enough time from your scientific inquires to expound on how I don’t understand medical realities*. I would expect that you had enough time to read the relevant material and respond in some way to the risks of SSR’s predatory approach.

          As it is, it appears that you think that it is VERY IMPORTANT to constantly note that acupuncture may have some useful benefit to some patients even when it is preformed by SSR – an MD of questionable competence who appears to be in the habit of actively deceiving patients regarding effective conventional treatment (SSR) so as to sell them placebos.

          Try not to set your standards TOO high pmoran.

    6. mousethatroared says:

      Okay – I’m done for now. Apologies to folks for my spam.

      I must make pine boughs, lightening bugs and a moth out of paper and clay now. Although I can thank pmoran for this image of an ivory tower that I have.

      Actually, that could be kinda cool.

      1. nancy brownlee says:

        I’d like to rent a room, please.

      2. PMoran says:

        Thanks a lot for your inattention, Andrey. Reread my last post and it will be clear to you that I was not accusing MTR of an “ivory tower” opinion. She was never mentioned therein and I would expect no less of her than that she would accept the general attitudes of this site towards such matters.

        1. Andrey Pavlov says:

          Thanks a lot for your inattention, Andrey. Reread my last post and it will be clear to you that I was not accusing MTR of an “ivory tower” opinion. She was never mentioned therein and I would expect no less of her than that she would accept the general attitudes of this site towards such matters.

          It was absolutely not clear, Madison and Mouse both picked up on that as well. And furthermore, it completely dismisses everything that Mouse actually had to say. Which you still haven’t actually bothered to respond to.

          You realize that there are only 3 options here:

          1) You are calling Mouse an ivory tower academic
          2) You were calling one of us IV academics
          3) You were calling Mouse’s thinking and words a blind parroting of us IV academics

          the last two seem most likely, and both of them indicate that you were not reading what Mouse had to say and willingly ignored addressing her points in order to continue trumpeting your acupuncture dogma. And yes, dogma is a very apt word because I’m pretty sure everyone here can predict exactly what you will write each time, despite it not quite making sense to us. In any event, you blather on about how we don’t actually discuss the “real patients” and have hifalutin discussions amongst ourselves – you know “ivory tower stuff” – and when a real patient and non-medical person takes you to task over something specific you proceed to hijack the conversation to drone on with your usual script, addressing people that aren’t even in the conversation (which is the most generous interpretation).

          and I would expect no less of her than that she would accept the general attitudes of this site towards such matters

          Let me rephrase the for you:

          “and I would expect her not to have thoughts of her own and just accept the SBM dogma and regurgitate that”

          You’re digging yourself a hole here and I suggest you put the shovel down and address the actual, real world, non-ivory tower, original, and critically thought out points Mouse put forward instead of having your continued imaginary conversation with us ivory tower dogmatic skeptic medical scientists. Or don’t. You don’t have to address anyone at all. But if you do say something, it should be on point or be willing to get called out on it.

  23. Stephen S. Rodrigues, MD says:

    I see my name is being used in vain. YEA!!! Too busy to play games now.

    1. windriven says:

      “I see my name is being used in vain. ”

      You are the only person using your name and your medical license in vain. You have demonstrated yourself to be a fool and a coward. A fool for abandoning medical science in favor of a theatrical placebo. A coward for lacking the willingness to defend your foolishness with hard cold evidence.

      1. Stephen S. Rodrigues, MD says:

        Me???? coward??? … not!!!! You are the avatar!

  24. Stephen S. Rodrigues, MD says:

    I am amazed that instead of doing some serious soul and thought processing, you guys are killing the messenger. Not the proper tactic for sincere scientist.

    Kill the person who has a different experience, idea, practice and tools. FEAR of failure and being wrong will push a person with a frail self worth into the attack mode.

    Deplorable.

    1. windriven says:

      “you guys are killing the messenger”

      That’s a laugh. You aren’t a messenger, you’re the court jester – only your act has worn thin.

    2. mousethatroared says:

      SSR – and by kill, apparently you mean to dispute or voice an opposing opinion in a sarcastic way.

      Doesn’t seem much like killing. It does sound like playing the victim in an attempt to gain sympathy, when confronted with evidence of your wrong doing….a strategy used often by predators and con men.

      1. Stephen S. Rodrigues, MD says:

        Kill is relative … yall are dead on arrival so that make me alive!!! :)

  25. Stephen S. Rodrigues, MD says:

    Joking … I’m not leaving:)
    I would have a place to proselytize.

    1. Harriet Hall says:

      Proselytizing doesn’t do any good if no one listens. No one here is listening to you except to laugh at you. Haven’t you noticed?

      1. Stephen S. Rodrigues, MD says:

        All of your patients are suffering in vain due to your material mechanical dogmatic view of medicine.

        Mind closure is the sad part for anyone who cares for patients and people! So do you ever look at your patients or talk to them or you just assign them a number to mitigate your shame.

        Feeling good about your role in AMA, the business side of medicine, big pharma, the medical device manufacturers love you dearly for helping to line their pockets. Waste, fraud and abuse are what you all are promoting by commission, omission and complacent deception.

        May God bless your patients, the poor souls who are being sacrificed with unnecessary and ineffective spinal, hip, knee, shoulder surgeries, overdosed with polypharmacy and strung-out on opiates.

        1. Harriet Hall says:

          “So do you ever look at your patients or talk to them or you just assign them a number to mitigate your shame.”

          Ha, ha! No, I never look at my patients or talk to them. I require them to cover their heads with a numbered paper bag and I don’t allow them to speak. :-)

          But seriously, I do feel really good about my role in AMA, which consists of not joining it. If everyone had the same role in AMA as I do, it would cease to exist.

          1. Andrey Pavlov says:

            But seriously, I do feel really good about my role in AMA, which consists of not joining it. If everyone had the same role in AMA as I do, it would cease to exist.

            I have no plans to join myself.

        2. Dave says:

          I’ve only been following this website for a few months but I have never seen any blog promoting the AMA, promoting the business of medicine, or talking about spinal surgeries, esi injections etc. I have seen comments pointing out studies showing certain surgeries may not be effective (the recent nejm article is a case in point) and Dr Hall has recently posted a list of things doctors are advised NOT to do, to the detriment of the bottom line. You have also felt that others have used ad hominem attacks on you, but I don’t see that this diatribe of yours (basically accusing others of waste, fraud and abuse) is anything other than an ad hominem attack on the ethics of others who do not agree with your therapies.

          You have however been asked to produce some valid evidence other than your personal experience that needle based therapy (I know you dont like the term “acupuncture” ) works better than placebo or sham therapy. We’re still waiting for that information. You also can certainly produce some valid references backing up your views on ESI injections etc. That would be much more effective than your current method of arguing.

          I agree with Dr Hall about the AMA. The majority of doctors apparently also agree with her.

          1. weing says:

            “I agree with Dr Hall about the AMA. The majority of doctors apparently also agree with her.”
            Given SSR’s posturing and record, I think we ought to re-evaluate our views of the AMA.

          2. Stephen S. Rodrigues, MD says:

            ESI’s are unnecessary option for low back pain. If you factor in the denial of viable alternatives and myofascial disease, I would convict the perpetrator of malpractice.

        3. WilliamLawrenceUtridge says:

          All of your patients are suffering in vain due to your material mechanical dogmatic view of medicine.

          What, you mean asking for evidence of effectiveness before subjecting patients to the risks of procedures or charging them for it? You mean continually re-examining existing practices to refine or abandon sub-optimal ones?*

          Yeah, we are the ones being dogmatic.

          *I’ll remind you that doctors who fail to adhere to best practice guidelines is a problem that does not justify the use of pseudoscience as an alternative. Doctors inappropriately performing spinal fusions or other surgeries means they need to stop doing these surgeries, it does not mean that acupuncture works or that your practice has validated.

  26. PMoran says:

    “Even Steve agrees with the potential of such influences. He is only able to describe acupuncture as “unnecessary”, “useless”, and “profitable” (i.e. presumed scam) by applying an in-house definition of it, and also a very broad “operational” definition of placebo.”

    My point in this is that the understandings those definitions are based upon can determine how the methods (“acupuncture” or “placebo”) are tested and how studies are interpreted. This has resulted in undue weight being given to studies that were never well-suited to the purpose to which they are being put.

    Andrey, you have experienced the power of non-specific influences at first-hand. Yet you, along with Hrobjartsson, Mark Crislip, Steve Novella and others still seem to adhere to the old notion that non-specific influences (which include those related to placebo) are, if anything, a constant small undercurrent within medical interactions, with more or less the same percentage of any population passively responding to more or less the same degree. (There probably is such an undercurrent but any scientific understanding of CAM requires us to also ask what might apply with a receptive patient and a very charismatic healer).

    You may not accept that you think like that, yet only by making that assumption can you rely on the meta analyses you refer to. These are pooled studies of pooled outcomes in clinical trials having extremely different characteristics and never primarily designed to test the strength of such influences.

    Yet this is now an unchallengeable dogma! — to the extent that with characteristic presumption and arrogance you chastise me for not buckling under when “things are explained to me”!

    You also accuse me of dogmatism when I have been very careful to refer to “what the science permits” and am clearly challenging very dogmatic statements in others.. (And I will NOT forgive you for translating my “ivory tower” criticism of Steve Novella onto MTR, who cannot in any way be held responsible for such views, until you apologise to both of us. )

    The fact is that everything changes when it is understood that both patients and populations will vary considerably, possibly even at different times, in their receptiveness to such influences, also that everything about the therapeutic interaction, ranging with probably little exaggeration from the color of the walls to how practitioners are dressed may make some contribution to how subjects will respond.

    If you read prominent “placebo-sceptic” Hrobjartsson’s recent papers. you will observe how he himself is bemused by the fact that some studies seem to show much stronger (and “clinically significant”) effects from acupuncture (both sham and real) than others. Yet this is exactly what you would expect from any modern understanding of this field.

    We can also not assume that even those responses represent an upper limit to what may be experienced by any individual, or by any given population “in the wild”, such as with an especially charismatic healer. (Again, as always, talking about subjective and psychosomatic complaints).

    H has reached the same point as I. We need a way fo distinguishing biased reporting from true symptomatic benefits, better coping, and other changes in illness behaviour before we can pronounce finally on these matters.. Then we can design studies that can actually answer the question. Until then normal scientific caution should apply.

    1. Andrey Pavlov says:

      I do not have time to respond fully (nor will I likely be able to till tomorrow) but one point to get out quickly:

      Yet you, along with Hrobjartsson, Mark Crislip, Steve Novella and others still seem to adhere to the old notion that non-specific influences (which include those related to placebo) are, if anything, a constant small undercurrent within medical interactions, with more or less the same percentage of any population passively responding to more or less the same degree.

      No, you have misunderstood me. I have been having a much more nuanced conversation than that, but you are insistent on spouting off your own particular acupuncture dogma. I’ll get more to it when I can.

    2. MadisonMD says:

      @Peter:
      You sound angry here. It wasn’t clear who was the object of your ‘ivory tower’ critique. Certainly you did not name Dr. Novella in your post even if you were thinking it. In fact, the generality of your responses– devoid of specifics such as who you are actually talking about– sows the seeds of confusion in your readers.

      As to your other points:
      * Variability. No one denied the variability of placebo response. However, a small average response means either:
      (a) most folks derive small benefit OR
      (b) an equal number derive more and less benefit (if median) OR
      (c) a small number have much greater benefit, but most have modestly less benefit than the average (if mean).
      We can’t argue this– it is simply what average means.

      *Prior acupuncture studies. You also seem to be saying acupuncture studies were not done properly or not grouped right in meta-analyses. Yet, we know that most were done by acupuncturists themselves and designed according its “practice.” So it is odd to state “This has resulted in undue weight being given to studies that were never well-suited to the purpose.”

      In short, you are trying to justify cherrypicking– cherrypicking responders within a study, and then cherrypicking studies which show the largest effects.

      We need a way fo distinguishing biased reporting from true symptomatic benefits, better coping, and other changes in illness behaviour before we can pronounce finally on these matters..

      We know that once we eliminate the biased reporting, the effects can only get smaller than with the biased reporting… and as we discussed elsewhere, 10-15ish points on a 100 point pain scale already isn’t much, even accounting for the variability. So who cares to “pronounce finally” that the true placebo effect of acupuncture averages, say, 7/100 on a pain scale? The type of navel-gazing research you propose is a wasted effort — the resources are best deployed on the discovery of non-placebo methods of alleviating pain.

    3. Andrey Pavlov says:

      @pmoran:

      Well, MadisonMD put it very well and I will try not to overlap too much.

      I know Madison touched on this but:

      My point in this is that the understandings those definitions are based upon can determine how the methods (“acupuncture” or “placebo”) are tested and how studies are interpreted. This has resulted in undue weight being given to studies that were never well-suited to the purpose to which they are being put.

      You simply fail to understand that the studies are the studies – they are operationally defined within themselves. The only time we here are re-defining them is when it is absurdly stupid to call it acupuncture in the first place – electroacupuncture is not acupuncture, it is TENS. And that study about using drug coated needles is also not acupuncture that’s just injecting fracking drugs into people. Otherwise, the definitions of the studies themselves is what we use and that is defined quite clearly, most commonly, and most accurately as “filiform needles inserted into specific sites for specific effects.” As Madison said it is the acupuncturists themselves designing the studies and determining what a “sham” is. They were surprised that the “sham” worked just as well as the “real thing.” But rather than take that to mean their “active treatment” didn’t work, they try and invent reasons why the sham also works or why the sham isn’t a good sham. That, Peter, is precisely the opposite of science. That is having a conclusion (that acupuncture “works”) and trying to shoehorn in why your results don’t support that. That is how the creationists do “science” – the experimental results must comport to the veracity of the bible or they did something wrong. In this case, the results must comport to the intrinsic efficacy of acupuncture or they did something wrong. So ridiculous conclusions like “the sham is also active” start getting bandied about.

      So no, you are unequivocally completely off the mark here.

      You may not accept that you think like that, yet only by making that assumption can you rely on the meta analyses you refer to

      I’ve explained this myriad times. Madison just did as well. I won’t repeat things. But try to understand what he (and I) are saying in regards to this. Somehow, magically, he has either managed to understand what I am saying or come to the same conclusion independently. You, after a couple years of this, seem utterly incapable.

      Yet this is now an unchallengeable dogma! — to the extent that with characteristic presumption and arrogance you chastise me for not buckling under when “things are explained to me”!

      What is unchallengeable dogma, Peter? That an average pooled effect that must include other influences that are artificially making the effect appear larger is simply not compelling evidence? Seems pretty fracking reasonable to me. Not my fault you don’t get it, no matter how many times, in how many ways, by how many people it is explained to you. MadisonMD said it well, so I leave you to his writing.

      You also accuse me of dogmatism when I have been very careful to refer to “what the science permits” and am clearly challenging very dogmatic statements in others..

      I am accusing you of dogmatism because waffley little caveats don’t actually count for much. It’s like saying “I don’t mean to be offensive…” and then saying something offensive. Just because you say you refer to “what science permits” and claim you are “challenging very dogmatic statements of others” doesn’t mean you actually are. And you aren’t.

      Creationists say the same thing – they are challenging the “unbending dogma of evolutionists and materialist paradigms.” Are they really the ones not being dogmatic, Peter?

      And I will NOT forgive you for translating my “ivory tower” criticism of Steve Novella onto MTR, who cannot in any way be held responsible for such views, until you apologise to both of us.

      I commented under a different comment of yours on this topic. As MadisonMD pointed out, it not only wasn’t clear to whom you were referring, but the only reasonable guess was Mouse, considering that you were involved in a conversation with her and responding to her at the time the comment was made. I’ve pointed out why that either shows you’re completely off the mark or simply ignoring the actual conversation with Mouse in order to continue bloviating on your particular acupuncture dogma.

      If Mouse feels I owe her an apology for something, I will gladly consider her views. You, however, do not deserve an apology from me and I have explained clearly why that stands. I’ve accused you in the past of muddied thinking and slippery writing and this is a prime example of it.

      And you still haven’t actually addressed any of the points Mouse raised.

      The fact is that everything changes when it is understood that both patients and populations will vary considerably, possibly even at different times, in their receptiveness to such influences

      Yes, this is true about everything. It is important to know. What are you trying to actually say beyond that?

      also that everything about the therapeutic interaction, ranging with probably little exaggeration from the color of the walls to how practitioners are dressed may make some contribution to how subjects will respond

      Yes, precisely right. I absolutely agree with you. For example, if a patient comes in and my exam room happens to be a particular shade of yellow and that patient recently lost his mother and her favorite flower was a tulip of just that shade or if that happens to be his favorite flower would lead to drastically different patient experiences and subjective outcomes.

      So…. what are you proposing? MadisonMD called it navel gazing and I think that is very apt. You are chastising us for not recognizing something that we do recognize and then trying to say we could and should study it further to truly elucidate and expound upon it.

      My critique (shared by many others here, I believe) is that this sort of stuff is firstly an overall rather small effect size and secondly – as you yourself have said it – highly variable. So we learn what the effect size of yellow rooms is and then everyone paints their room yellow. Then something happens and the popular media shifts and yellow is now passe or associated with some tragic event. We investigate the effect size of this and decide green is a better color. What have we accomplished? Wasting a lot of time and money for a phenomenon already reasonably well understood.

      You are, in essence, asking to quantify and objectify bedside manner. I think it is a much better tack to understand this variability and use our interpersonal skills to accommodate the individual in front of us. That will literally be the last thing that a physician can do to be replaced by a computer.

      If you read prominent “placebo-sceptic” Hrobjartsson’s recent papers. you will observe how he himself is bemused by the fact that some studies seem to show much stronger (and “clinically significant”) effects from acupuncture (both sham and real) than others. Yet this is exactly what you would expect from any modern understanding of this field.

      Yes, and it is precisely what I would expect as well. And, as you have noted, experienced myself. Funny how you decide to cherry pick only one aspect of my experience – the part that supports your stance – and ignore the part that completely undermines it.

      But you are asking us to go outlier hunting. To find some way to identify those people that will experience that significantly heightened effect (yes I know we are talking about subjective experiences) in order to take advantage of it. Yet the part you are missing is that because of the variability and transitory nature of these effects, you are chasing a ghost. And a pretty small one at that.

      What is your solution to how to actually do this? You complain that pooled analyses smooth out those outliers. Yet we work on a pooled patient population. Who do I then recommend to go get acupuncture? Oh right, you agree that we can’t recommend acupuncture. So then do I do acupuncture? On whom? The pooled data show it is pretty worthless or marginal at best. Is it really worth my time and the patient’s time and money to try and single those people who I might think are good responders out? No, you agree we can’t quite do that either. So what do we actually do Peter?

      So now lets say your navel gazing pays off and we do determine the actual effect size of those non-specific influences separate from the artifacts of study. Now what? As MadisonMD pointed out (and I have been saying for years) that effect size must be smaller still! And we still don’t know who will actually be those big responders. Any guess why? Because of that highly variable nature! OK, so now what? What the frack am I supposed to do with this much more accurate and detailed scientific information? What am I supposed to advise my patients?

      “Well Mr. Smith, thankful Peter Moran has shown us that the average person gets a barely noticeable but still present effect from everything about acupuncture except the actual acupuncture, but that some people have really big responses. Perhaps you’ll be one of those lucky people for a while and you can go see an acupuncturist if you think that your particular current cultural paradigm is amenable to the suggestible and non-specific effects of acupuncture.”

      Well that just seems silly.

      We can also not assume that even those responses represent an upper limit to what may be experienced by any individual, or by any given population “in the wild”, such as with an especially charismatic healer. (Again, as always, talking about subjective and psychosomatic complaints).

      Sure. Same can be said for faith healers, snake handlers, Peter Popoff, and any number of highly charismatic charlatans and predators. You’ve heard of those old people in nursing homes who give all their money to shysters who are charismatic and make them feel so good about themselves? It happens, and it is really hard to disabuse them of the notion that they have been helped and they genuinely feel better about themselves. That is all that acupuncture is, but just less malevolent.

      Until then normal scientific caution should apply.

      Yes, I agree. And the normal scientific caution is “this effect does not exist and is not useful until proven otherwise.” It hasn’t met that criteria yet and the correct scientific stance – after thousands and thousands of studies that are precisely what you would expect with a small or non-existent effect that is highly variable across time and population showing nothing but some noise with an incredibly hard to pick out signal – is that there is no worthwhile effect. You are being unscientific in assuming it is there, that it is useful and clinically significant, and that somehow I need to prove to you that it isn’t. And worst of all you are doing it by cherry picking a few out of the myriad studies that best support that stance, ignore or rationalize all the others, and spin a just-so story to try and give a little more Bayesian prior to your undemonstrated conclusion.

      The crux for last:

      Andrey, you have experienced the power of non-specific influences at first-hand. Yet you, along with Hrobjartsson, Mark Crislip, Steve Novella and others still seem to adhere to the old notion that non-specific influences (which include those related to placebo) are, if anything, a constant small undercurrent within medical interactions, with more or less the same percentage of any population passively responding to more or less the same degree. (There probably is such an undercurrent but any scientific understanding of CAM requires us to also ask what might apply with a receptive patient and a very charismatic healer).

      Yes I have. And as I said above, you cling to that and ignore everything else I have to say about it. People have also experienced the amazing healing power of Peter Popoff first hand – and way, way more profoundly than anything I have ever experienced. But I don’t see you arguing for using Peter Popoff as a medical adjunct.

      I also do not think that placebo is just a small constant undercurrent within medical interactions, and so on. I have actually explained numerous times quite clearly, with data, with personal anecdotes, with thought experiments, why I do not actually believe this. So don’t get mad when I accuse you of being dogmatic and unchanging when things are explained to you because it is quite clear you don’t actually read what is put before you and continue your own spiel, always unaltered, as if these points weren’t addressed. Which is why it is perfectly reasonable for me to say that you are being dogmatic; you are.

      My argument is much more nuanced than that but at this point I have wasted enough of my time responding. I would try and explain it, again, but it is clear you have no interest in actually reading it. Many other people have understood it or come to the same conclusion independently. But you are like a creationist when it comes to your acupuncture.

      1. Stephen S. Rodrigues, MD says:

        You guys want me to prove that Acupuncture is a valid therapeutic modality here on this site that are full of alternative medicine naysayers trapped in a dogmatic paradigm? Impossible! You all have access to the web and research sites, so prove or disprove it to yourself. Sorry that is not my responsibility. You have proven to me that you can not break out of your paradigms of dogma.

        Besides ALL you all disavow alternatives thus are promoting conventional, one size fits all, pushbutton, high-technology, wasteful, fraudulent and abusive medicine. Did you know that modern medicine is not perfect and has flawed procedures, standards and concepts? Thus by de facto you are working and promoting for the FDA, DEA, AMA, Big Pharma, Big manufacturers, opiate diversion, illegal drug culture and on worthless supplements.

        Do you think that for all of humanity (dumb and stupid) people had no idea how to treat pain and misery? Where are the records of all the crippled and invalids who wasted away with joints that just fell apart? Show me where scientists have uncovered ancient bones of workers who showed signs of moderate to severe degeneration of the joints.

        I have no problems with a lot of what modern medicine has to offer, we all kinda know where those successes are but it falls short in a large segment of care and that is pain and conundrums.

        My responsibility is to all the patients in need for a alternatives that will help them have a better quality of life. Yes I am dogmatic about what I have found to be effective and curative in some cases. Metallic needles do what they naturally do which is to stimulate healing and depolarize muscles which is a profound benefit to diseased muscles.

        1. AdamG says:

          Show me where scientists have uncovered ancient bones of workers who showed signs of moderate to severe degeneration of the joints.

          OK, sure:
          http://www.ncbi.nlm.nih.gov/pubmed/20564538
          http://www.ncbi.nlm.nih.gov/pubmed/17711424
          http://www.ncbi.nlm.nih.gov/pubmed/11745080

          There’s plenty more where that came from.
          You have access to the web and research sites too, maybe you should research such spurious claims before you state them as fact.

          1. Stephen S. Rodrigues, MD says:

            OK, sure:
            http://www.ncbi.nlm.nih.gov/pubmed/20564538
            “No change over time was observed in the prevalence of degenerative joint disease.”

            No change means no increase or decrease … so why have the AMA and the SBM community sanctioned the removal of a viable joint to relieve pain?

            They disavow alternatives thus sacrificing a patient bones and joints to the dogs for sake of science dogma despotism.

            Joint replacement surgery, in the vast majority of cases are not necessary.
            Joint replacement surgeries in a lot of cases is devastatingly detrimental to a lot of patients.

            Acupuncture (modern), dry needling, wet needling, trigger point injections, prolotherapy, biopuncture are options in the world of myofascial release therapy with needles which should be the standard of care for all myofascial pain and dysfunctions. These alternative therapies have been around from the beginning of time and are vetted, natural, curative and safe,

            Important when I use the word “Acupuncture” I’m referring to the use of needles in the broad category of MFR therapy.

            Traditional Chinese Acupuncture (TCM) = the ancient art of the use of needles as part of Chinese Medicine.

            1. mousethatroared says:

              Your reading comprehension seems to be a problem. The were no change between the pre-Neolithic and the Neolithic skeletons. They are not saying no age related changes in the individual skeletons.

            2. MadisonMD says:

              Incredible. It would seem impossible to graduate from medical school or to get ABFM certification without learning the meaning of ‘prevalence.’ But the evidence before me seems irrefutable.

              1. Stephen S. Rodrigues, MD says:

                Can’t see the forest for the trees. Not good for a clinician, researcher or scientist.

            3. WilliamLawrenceUtridge says:

              Hi Steve,

              I got a copy of the PDF for the article you cite. Note some quotes:

              “Degenerative joint disease is the most common pathological condition in prehistoric populations”

              “No significant differences were found in the prevalence of arthritis in the postcranial bone (3.0% for the Natufians and 2.5% for the Neolithic, Fig. 2).” (adults and children)

              “There is no significant difference between the Neolithic and Natufian males in the … prevalence of arthritic lesions
              (8.6% vs. 7.8%, respectively, Fig. 3).”

              “Additionally, no significant difference was found in the prevalence of arthritic lesions (6.5% and 5.6%, respectively, Fig. 4)” (females)

              The paper you cite does not break down the percentages according to adults overall, but it is rather obvious that arthritis was not a rare phenomena among pre-modern people. Further, the information on the actual ages of death is in another paper by the same author, so we have no idea what the average age of death was in each of these populations.

              Also, I am not a doctor, but I’m pretty sure joints are not removed or replaced simply on the basis of pain. I’m pretty sure you need proof of joint degeneration via x-ray, MRI, or some other empirical evidence. In other words, you are simply making stuff up. It’s easy to condemn an entire profession when your condemnation is based on facts you made up solely to show how evil the profession is. It’s harder if you want your criticisms to be based on reality. I mean, sure, everyone can agree that Obama is the worst President ever if you include as a fact that he must eat a thousand babies per day to stay alive, is actually responsible for 9/11, personally tortures every single inmate of Gitmo on a daily basis, and drops a nuclear bomb on a random third-world city every week. It’s a little more difficult to come to such an agreement if we restrict ourselves to reality though.

        2. MadisonMD says:

          You all have access to the web and research sites, so prove or disprove it to yourself.

          Done.

          1. Stephen S. Rodrigues, MD says:

            Don’t believe what your read in medicine you can die from a misprint!

            1. MadisonMD says:

              Was that your rationalization for not reading your textbook assignments in medical school? If you had read it, you would have learned the meaning of ‘prevalence.’

  27. Sawyer says:

    Thus by de facto you are working and promoting for the FDA, DEA, AMA, Big Pharma, Big manufacturers, opiate diversion, illegal drug culture and on worthless supplements

    DEA. I now work for the DEA. And the illegal drug culture. At the same time.

    Wow, just …… wow.

    1. Stephen S. Rodrigues, MD says:

      Yes the DEA and the drug cartels, both sides of the drug war.

      Without viable alternative pain therapy patients have to get drugs, pills and comfort from illegal sources.

  28. P Moran says:

    Madinson MD “Steve”, meaning Steve Novella, was the only person mentioned in that post and it was his views that the “ivory tower” comment clearly referred to. Go check. Why on earth would I refer to MTR this way? This was sheer inattention on Andrey’s part.

    That is also not what is meant by “cherry-picking”. It implies the selection of positive results over equally forceful negative ones.. We don’t yet know that all those studies have equal force as a test of psychological and non-specific influences because they were never set up with that in mind and typically they vary so greatly in other ways.

    It is in the nature of the influences being assessed that they would vary considerably from study to study unless considerable effort was made to recruit identical patient populations, and then give them exactly the same information and treat them in identical ways. We now know that some of these very same influences can either enhance or reduce the effect of active pharmaceuticals, so there should be no problem with that point. We merely don’t have to take it into consideration so much when dealing with agents having intrinsic physiological activity

    And whether the effects are small when spread over all participants, or strong in only a few, if you accept the reality of “placebo and nonspecific influences” at all you could be on my side against overly dogmatic pronouncements on that matter.

    Your best point is that that acupuncturists are involved in these studies and will be wanting to mimic normal practice, yet the instant patients learn that they may not be receiving a “real” treatment their expectations are likely to be dampened. Also, in order to try and sustain patient blinding, practitioners may well be discouraged from some kind of patient interactions. It is an artificial situation that cannot be assumed to closely mimic “normal” practice. Without an objective surrogate for true patient benefit the whole matter is difficult to study.

    1. MadisonMD says:

      “Steve”, meaning Steve Novella, was the only person mentioned in that post

      Well, “Steve” was two paragraphs above the ivory tower, it said “even Steve agrees…” and in fact, I misunderstood it to mean SSR, since nobody else was writing of Dr. Novella in the thread. Perhaps you can forgive the misunderstanding amongst your readers.

      That is also not what is meant by “cherry-picking.”

      Perhaps I read too much into your protestations about variability in patient outcomes and variability in study outcomes?

      It is in the nature of the influences being assessed that they would vary considerably from study to study unless considerable effort was made to recruit identical patient populations, and then give them exactly the same information and treat them in identical ways.

      So? Variability is in the nature of every study. If it wasn’t you could enroll one patient on each arm. You are not going to eliminate variability. If you could, your results would have no meaning in the real world.

      We now know that some of these very same influences can either enhance or reduce the effect of active pharmaceuticals, so there should be no problem with that point.

      ?? You are claiming that people might be having more pain relief from acupuncture than they are actually reporting? That seems highly improbable. Pray tell, how would that happen?

      And whether the effects are small when spread over all participants, or strong in only a few… you could be on my side against overly dogmatic pronouncements on that matter.

      I’ll keep my own opinion about which interpretation is ‘dogmatic’ and which is ‘evidence based,’ thank you! We previously established that mean acupuncture placebo effect on pain is 10-15 on a 100-point scale. Facts is facts.

      … yet the instant patients learn that they may not be receiving a “real” treatment their expectations are likely to be dampened. Also, in order to try and sustain patient blinding, practitioners may well be discouraged from some kind of patient interactions. It is an artificial situation that cannot be assumed to closely mimic “normal” practice.

      You keep making up reasons why the studies show a smaller placebo effect than you want them to show. Perhaps you are correct and these are the reasons that acupuncture seems to have a very small placebo effect. Yet it’s also possible that acupuncture actually does have a very small placebo effect. Why deny it?

      Without an objective surrogate for true patient benefit the whole matter is difficult to study.

      As I said, you often end with “a bland generality of dubious verity, but not easily falsifiable.” But the engagement was nice–thank you.

      1. PMoran says:

        “You keep making up reasons why the studies show a smaller placebo effect than you want them to show.”

        No, I need to know for the honesty of my own interchanges with CAM users and practitioners what these influences are capable of under favorable conditions, and that requires studies that are designed to answer that specific question. This is basic scientific procedure and there is ample foundation for the relevant hypothesis in both plausibility and observational evidence.

        When large acupuncture studies of sufficient quality to figure in a Hrobjartsson meta-analysis have effect sizes over “usual care” in excess of 0.9 I can do no less than ask whether less exertion of psychological/non-specific influences is responsible for weaker results in other studies (now that I think of it, there may be enough information in the published data for that question to be looked at). .

        Effect sizes of that degree will certainly reflect a greater than 10 mm improvement in pain, as someone probably not so suffering has deemed “minimally clinically relevant” to a population with chronic pain.

        Once I know the answer to this I will be surer about how to talk to others about some unusual medical experiences.. In the meantime I will have to allow to some CAM practitioners that they “probably are helping some patients in limited ways”. and I will feel obliged to object when anyone is too dogmatic in denying that.

        I don’t see this as having any major impact on how the mainstream chooses to practice.. Medical scepticism has a deeply entrenched “don’t go there — (don’t even think about it!)” general attitude to such questions but this lack of attention to such a central matter has allowed the notion to persist that by giving an inch on it we should be having to recommend homeopathy and therapeutic touch to our patients next week. This is what Windriven and some others seem to think.

        Yet a little further thought reveals that this is just not true. There are many reasons why we would not do that. At most there would be a small shift of our public attitudes towards some aspects of CAM that might bring them closer to those we actually adopt in private with our patients.

        1. MadisonMD says:

          Peter,
          We seem to be covering the same ground with different words. You are, in essence, saying we cannot rule out that a large medically placebo effect of acupuncture is effective in some cases… and that more research is needed to convince you it doesn’t work. Until then you will believe that it would be OK to recommend acupuncture.
          I disagree with your assessment. I would require some evidence that the benefit/risk ratio of the intervention is worthwhile prior to recommending it. Existing data are not favorable. You provide some possible reasons that true benefit is underestimated and could be uncovered in a future study. However, it is also possible that there is no major placebo effect to be uncovered.

          If you have other data/citations, I’m interested, but there is not much value in restating these positions.

          ( I’m not sure why you bring Windriven and others into it. I don’t recall him or others making the slippery slope argument you describe. I do recall some commenters using parallels to show for example, that their appraisals of homeopathy and acupuncture are consistent.)

          …probably are helping some patients in limited ways

          I agree with this assessment. But I have a problem in that it avoids the costs/risks part of the therapeutic equation– isn’t that important?

    2. Andrey Pavlov says:

      Madinson MD “Steve”, meaning Steve Novella, was the only person mentioned in that post and it was his views that the “ivory tower” comment clearly referred to. Go check. Why on earth would I refer to MTR this way? This was sheer inattention on Andrey’s part.

      I did go check. And, as MadisonMD pointed out, it really wasn’t clear. All of a sudden, after a number of back and forths with Mouse, you bust out that comment. And of course you wouldn’t directly refer to Mouse as Ivory tower, which is why I included the other possibilities and clearly stated I thought the one of you actually referring to her as ivory tower was the least likely. More likely, as I said before, is that you are continuing to write in a slippery and vague way and looking for any whisper of a reason to keep spouting your acupuncture and non-specific effects spiel. In other words, you weren’t actually engaging Mouse but talking past her in order to repeat the same thing we’ve heard a million times. Go back and check – you’ll see that is exactly my point when I wrote before.

      You don’t write clearly, you close with these vague and almost meaningless statements (once again as MadisonMD points out), you obfuscate and muddy the waters with wishy-washy terms, and now, worst of all, you admit there is no data and yet you say the more scientifically sound stance is to act as if it is there. I’ve accused you of these things numerous times and my discussion of the ivory tower was an example of that not me seriously accusing you of calling Mouse ivory tower (though you did essentially say that her thoughts are not her own and she is just parroting our ivory tower views). It is your inattention because all you care about is repeating ad nauseum your “scientifically sound and rigorous” speculation as to what may be hiding in the data.

      That is also not what is meant by “cherry-picking”. It implies the selection of positive results over equally forceful negative ones.. We don’t yet know that all those studies have equal force as a test of psychological and non-specific influences because they were never set up with that in mind and typically they vary so greatly in other ways.

      And yet you assume it to be so and when we here say that all the data shows us nothing is there, that the effect size must be small if existent at all, and therefore the null hypothesis is “there is no clinically useful effect” somehow we are the ones being dogmatically unsound in our science? That’s absurd.

      It is in the nature of the influences being assessed that they would vary considerably from study to study unless considerable effort was made to recruit identical patient populations, and then give them exactly the same information and treat them in identical ways.

      Actually I would argue that there would still be significant variation even with the identical patient population because the very nature of these effects is non-specific, subjective, and depends entirely on the cognitive filter of the person receiving it! Which completely undermines its utility.

      We merely don’t have to take it into consideration so much when dealing with agents having intrinsic physiological activity

      So when there is intrinsic physiological activity these effects don’t really matter. But when that is all there is, with no intrinsic physiological activity (which you have in the past argued that there is for acupuncture…) then we need to accept them as there and robust, despite a lack of evidence, and it becomes unreasonable to reject the treatment as “not working”? You see Peter, this is the problem – you don’t actually have a consistent stance on the matter. You focus on acupuncture to the exclusion of all else and mount an argument that seems reasonable until your realize that it applies equally well to things like homeopathy, faith healing, and snake handling. If the same argument with the same sort of conditions can be made for homeopathy, then it isn’t a good argument.

      placebo and nonspecific influences” at all you could be on my side against overly dogmatic pronouncements on that matter.

      I accept that stance. I’ve said it a million times before. So how am I still being “overly dogmatic”?

      Your best point is that that acupuncturists are involved in these studies and will be wanting to mimic normal practice, yet the instant patients learn that they may not be receiving a “real” treatment their expectations are likely to be dampened. Also, in order to try and sustain patient blinding, practitioners may well be discouraged from some kind of patient interactions. It is an artificial situation that cannot be assumed to closely mimic “normal” practice. Without an objective surrogate for true patient benefit the whole matter is difficult to study.

      Well, besides what MadisonMD said, this is called special pleading. And that is patently unscientific.

      1. PMoran says:

        Andrey: ” — placebo and nonspecific influences” at all you could be on my side against overly dogmatic pronouncements on that matter.”

        I accept that stance. I’ve said it a million times before. So how am I still being “overly dogmatic”?”
        ______________________________
        PM Well, what am I being attacked about? For reacting to a comment of Sawyer’s that you now also don’t agree with? For challenging Steve Novella on the same grounds? That makes no sense.

        I have tried to understand your previous long response. You still don’t seem to get my unchallengeable point that you cannot determine the potential strength of the placebo/non-specific influences of a treatment program without designing studies that you can know are strongly exerting such influences with a minimum of potential interference. We don’t know that of the studies being quoted and I don’t care which medical bigwigs seem to be also making that assumption. .

        Your fabled “nuance” on placebo effects has the curious quality of enabling you to hold to substantially different positions all at the one time.

        We have: “And the normal scientific caution is “this effect does not exist and is not useful until proven otherwise.”” (Implies that medical science has to operate on an “all or nothing” basis, when it actually operates within a wide ranges of probabilities.)

        Then we have: , — “the pooled data show it is pretty worthless or marginal at best” — which leaves not much room for your opinion that any effects will also “highly variable .” both at individual and population level.

        Then: “I absolutely agree with you. For example, if a patient comes in and my exam room happens to be a particular shade of yellow and that patient recently lost his mother and her favorite flower was a tulip of just that shade or if that happens to be his favorite flower would lead to drastically different patient experiences and subjective outcomes.” (My emphasis)

        Which conflicts with most of the rest. Please don’t try and justify all this. I do understand. Until the advent of CAM hardly anyone was giving serious thought to what it meant to “work as placebo” or how to investigate it, with the result that this is a rather confused field with good minds holding very different opinions. .

        My comments to MadinsonMD have a bearing on your other points, such as the notion that holding of certain views necessitates some kind of wholesale embrace of pseudoscience. It doesn’t . It might lead to better things in other ways.

        1. weing says:

          “You still don’t seem to get my unchallengeable point that you cannot determine the potential strength of the placebo/non-specific influences of a treatment program without designing studies that you can know are strongly exerting such influences with a minimum of potential interference.”

          I don’t know what this means. Potential interference from what? Actual treatment?

          1. MadisonMD says:

            I concluded that the opaqueness of the statement is what made it unchallengeable. But, seriously, *I think* he is saying is that if we select the most suggestible patients, prime patients more, and make acupuncture even more theatrical, then it could have a strong enough placebo effect to be clinically useful.

            It really boils down the cherished hope that future studies on acupuncture will use an improved methodology compared with the 20,235 published already*. These future studies, Peter believes, if done properly**, will finally reveal a strong and sustained placebo effect, allowing Peter to be ultimately vindicated.

            *Pubmed
            **Limited specifics are being provided on what Peter believes would finally constitute a properly designed study.

            1. PMoran says:

              “These future studies, Peter believes, if done properly**, will finally reveal a strong and sustained placebo effect, allowing Peter to be ultimately vindicated”

              Well, not so much me. I can wear whichever way it goes while believing that a resolution is a long way off unless we can develop more objective surrogate measures for beneficial outcomes.

              Why? Because it is entirely predictable that strenuous measures would produce clinically significant reported outcomes. That is happening right now. But we would still not know whether any individual “outcome” or collection of outcomes was due to biased reporting or whether some patients were in fact being jolted out of some kind of illness cycle or having their symptoms usefully, if mainly temporarily, relieved..

              Certainly some of the claims concerning outcomes from CAM use in subjective and psychosomatic conditions might end up being vindicated.

              That would still not mean that such methods should be endorsed for routine mainstream use, partly for the same reasons that make such outcomes so difficult to reliably measure. They would be of uncertain cost-effectiveness within the different environments of mainstream medical practice especially if advised by doctors with varying interest and attitudes towards them..

              1. Andrey Pavlov says:

                I’m getting quite tired of the back and forth myself. MadisonMD has done an admirable job and is clearly on the same page as I.

                So how about this.

                I declare, henceforth the following:

                1) Non-specific and genuine placebo effects (as I have differentiated them from placebo responses) are beneficial to patients (and the nocebo is detrimental)
                2) These effects are helpful for subjective and otherwise psychological conditions but do not alter the course of objective conditions or disease states, except wherein decreased stress/anxiety leads to decreased circulating catecholamines/corticosteroids (and the relevent downstream effects of chronic increased levels)
                3) These effects are real and can be quite profound in very specific cases (which require maximal exploitation of practitioner practices and patient susceptability to the particular method of delivery)
                4) That is is likely that acupuncture, just like any other placebo based pseudomedicine (homeopathy, reiki, reflexology, faith healing), has some genuine effect including quite profound effects on some people at some times.
                5) That, on the whole, the data shows that this effect is small with the occasional data of significantly larger effect sizes (see point #4)
                6) That there is no evidence to support the idea that these effects are sustained and at least some to indicate it is ephemeral*
                7) That practitioners who use such techniques are indeed doing some of their patients some good, although it is likely not very much and not outweighed by the harm they bring on the whole.
                8) There is no place for purely placebo medicine (which acupuncture is) in modern medical practice as a stand-alone therapeutic, whether performed by the physician or referred to an acupuncturist by the physician
                9) That in the commonly accepted vernacular and the traditionally accepted scientific jargon acupuncture does not work in that it does not outperform placebo since it is unequivocally nothing more than theatrical placebo. It only “works” in the narrow sense of placebo and non-specific effects, and it certainly does not work by any of the mechanisms proposed by the overwhelming majority of studies on the topic or the acupuncturists themselves or the commonly accepted lay understanding of acupuncture.**
                10) That we do not know what the potential maximum effect size of acupuncture is given optimal circumstances and subjects, as those studies have not been done.***
                11) That all of this is arguing about how many angels can dance on the head of a pin since no matter how one slices it, short of stupdendously large effect sizes that are, based on the data so far, extremely unlikely acupuncture is a modality that doesn’t “work” and doesn’t have a rational place or scientific basis for the health care of any identifiable population.

                Does that settle it? Can we agree on that and just move on?

                * The exception to this would be in cases of psychological change leading to sustained behavioral changes. For example the depressed overweight person with chronic joint pain sees an acupuncturist, gets motivated, loses weight, feels less pain, depression lifts, and now leads a fundamentally different lifestyle. But I would not call this a direct effect of the non-specific and placebo effects of acupuncture.

                **Unless you are willing to say that a placebo pill vs an actual test drug “works” when the placebo pill and the tested drug have the same exact outcome, you cannot argue that sham acupuncture “works” and thus acupuncture “works.” Either the placebo arm of Xigris “worked” and we should now market both, unless homeopathy “works”, then acupuncture cannot “work” either. It is a double standard to now say that because there are non-specific and placebo effects and these are not overshadowed by the intrinsic effects (because there are none) that acupuncture “works” via these mechanisms. That is not the common or scientific understanding of the term and while understandable as to why one might argue that, it serves nothing except to muddy the waters and sow confusion as to what about acupuncture “works” (which is everything about it except what acupuncturists and the common person would actually call “acupuncture”).

                *** Which means two things. The first is, that the unscientific position is to presume those effects are there. You can posit them and I would agree they could very well be there, but you don’t have the data to assert that they are. Secondly, it is a moot point anyway. Certainly not any sort of idea worth spending the money to pursue when there are vastly more worthwhile goals to pursue in medical research. If you wish to investigate the placebo effect and the responses and how those work, by all means. But acupuncture is not a necessary vehicle by which to do it. While it could be used in principle, the waters are already so muddied with ideological belief in acupuncture that it is far from the ideal vehicle by which to investigate placebo and non-specific effects.

              2. mousethatroared says:

                MadisonMD – If the effects are intrinsic to CBT, then it is not placebo. However, if a study showed equivalent outcomes of CBT and a control arm (i.e. where you chat with a friend over coffee), then the effects would not be specific to CBT. In that case I would call the effects ‘placebo.’

                Good point! Although, I will be open and say I’m not sure how either having coffee with a friend or CBT are “inactive” psychological activities. And I thought the point was to compare an active therapy to an inactive therapy. If you are treating someone with depression or anxiety it’s very possible that they are isolated and meeting a friend would provide a specific benefit that meeting with a stranger or CBT would not, correct? or not correct?

                I know that they often use being put on a wait list as a control for psychological therapy trials. Do you think that’s an adequate placebo? I’m not sure I do.

              3. MadisonMD says:

                @MTR

                If you are treating someone with depression or anxiety it’s very possible that they are isolated and meeting a friend would provide a specific benefit that meeting with a stranger or CBT would not, correct? or not correct?

                Point taken– yes, meeting with a stranger is better control to show the effect is specific to CBT. Yet, I’d also hope CBT is more effective and durable than meeting a friend.

              4. mousethatroared says:

                MadisonMD – “Yet, I’d also hope CBT is more effective and durable than meeting a friend.”

                By brain is darting around like a border collie that’s been in the crate all day and is looking for all sort of exceptions and qualifications. I’ll assume that if it’s annoying to me, it’ll REALLY annoy anyone else. So,

                Within the context of chronic pain with no other comorbid mental health conditions, assuming a course of CBT vs one meeting of coffee with a friend (who isn’t qualified as a mental health counselor), then sure, I’d hope it would be more effective too.

            2. mousethatroared says:

              I’m not against research just to suss out interesting interactions, but I just don’t get the real world application of a purely placebo interventions.

              From a patient’s perspective, it seems to me that any person with chronic pain will have already tried various interventions in the diagnostic and treatment phases of their disease. I have been treated for painful conditions that lasted months-to over a year on several occasions. Plantar fasciitis, SI joint dysfunction and then recently this Cervical radiaculapathy.

              In each case there was a trial of anti-inflammatories (active intervention plus placebo), then PT which incorporated several approaches. PF, exercise, shoe inserts, some sort of steroid salve applied with electrical instrument, then deep tissue massage (trigger point therapy). SI Joint – exercises, TENS, ultra sound, deep tissue massage, CR – neck collar at night, exercises, ultra sound, TENS, joint mobilizations, massage.

              If most people with chronic pain get similar treatment (that is my assumption here, since my experience was pretty similar on three different occassions and similar to others with muscular-skeletal pain I’ve talked to.) then why isn’t that person who just needs a dramatic intervention being jolted out of their “sickness cycle” with one or more of those interventions? What is the value of “just one more” intervention when the patient has already probably tried 3 to 7 (guesstimate) interventions already?

              *As an aside, don’t think of CBT as a placebo intervention, anymore than I think of driving class as a placebo intervention, it’s intent is to teach skills. If are going to think of teaching mental skills as placebo, we should just dissolve out school systems and give all the kids a sugar pill instead.

              1. weing says:

                @MTR,
                To me it appears to be a quest for a placebo for a placebo.

              2. Andrey Pavlov says:

                As an aside, don’t think of CBT as a placebo intervention, anymore than I think of driving class as a placebo intervention, it’s intent is to teach skills

                Agreed, to me that is an active intervention as well and I have argued that many times here. It is as simple as thinking about what we tend to consider active interventions. If something is wrong with you heart muscle and I tickle your feet and you feel better, that is placebo. But if I give you a drug (or therapy or intervention) that directly affects the molecular and physiological make up of your heart that is plainly an active intervention.

                If your condition is wholly or partly psychological* (as in pain) then that means something “wrong”** with your brain and doing something that we know alters the molecular and physiological (and physical) structure of your brain should also be an active intervention. And we know that CBT and all interaction does exactly that, so it seems reasonable to call it active.

                But we do not add in extra things that are themselves not having that active effect. We don’t poke you in the cheek every 5 minutes while doing CBT, so we needn’t poke you with needles to achieve rest, relaxation, and all the other things that actually are having the effect in acupuncture.

                *I hate that I have to say this, but to really avoid confusion, psychological does not mean “not real.” It is just referring to the origin or contribution to the issue the person is having.

                **”Wrong” in precisely the same sense as your heart muscle going “wrong”. The brain is an organ and can suffer pathology as well, but we’ve a bad history of dualistic thinking to marginalize psychological illness so I wanted to be really clear.

              3. mousethatroared says:

                @Andrey – Yes, we appear to be on the same page, although our analogies differ.

                as an aside – “*I hate that I have to say this, but to really avoid confusion, psychological does not mean “not real.” It is just referring to the origin or contribution to the issue the person is having.”

                Just to clarify, is this in response to something I said? I didn’t mean to indicate that I thought of pain that was primarily psych/social in origin was not “real”. But, if I came across that way, I’d like to know, just so I can avoid doing it again in the future.

                I do think that there might be some confusion caused by the use of the term “chronic pain”. I get the sense that some commenters are thinking of pain that is predominately psycho/social in origin. While I am thinking of it as pain of any origin (bio/psycho/social) that is longer than six month. This would include chronic migraines, rheumatoid and osteo-arthritis (and others), SLE, congenital disorders, etc, on and on. Even Fibromyalgia, a condition that many on this board seem to think of a primarily psycho/social in origin, I think of as incorporating a real bio* component, since most of the people I “know”* with fibro also have co-morbid auto-immune diseases (RA, Sjogren’s, SLE, Diabetes).

                *bio – meaning either caused directly by the immune dysfunction attacking the nervous system or as secondary effect of the diseases biological activity and I have no idea where people categorize central sensitization in that rather arbitrary separation between neurological or psychological.

                **often people I know through online forums.

              4. Andrey Pavlov says:

                @MTR:

                Just to clarify, is this in response to something I said?

                No, not in the slightest. Mea culpa for not being clear in my attempt to be clear. It was merely perfunctory on my part. I hope that people who know my writing here will have not needed me to include those explanations, yourself included, but I feel like we (the royal we in this specific context) are mired in a lack of clarity for the sake of trying to be too clear. I just didn’t want someone else (e.g. other than those who know my writing) to seize upon some opportunity to twist my words into the hackneyed narrative of the pedantic scientist who cares and believes not in the reality of subjective concerns.

                While I am thinking of it as pain of any origin (bio/psycho/social) that is longer than six month

                I believe this is correct. That can then be subdivided into various categories depending on the root causes, modifiers, perpetuators, and extinguishers of the pain. These can exist in just about any conceivable conformation and proportion.

                Even Fibromyalgia, a condition that many on this board seem to think of a primarily psycho/social in origin, I think of as incorporating a real bio* component

                I have no doubt that some subset of what is called “fibromyalgia” has such a “bio” component, but that we merely do not know what that is, how it operates, or how to identify it. Our ability to resolve the etiology is crude to the point where it becomes a wastebasket diagnosis of exclusion for that reason alone.

              5. mousethatroared says:

                Andrey “I just didn’t want someone else (e.g. other than those who know my writing) to seize upon some opportunity to twist my words into the hackneyed narrative of the pedantic scientist who cares and believes not in the reality of subjective concerns.”

                Understandable – just wanted to check.

              6. MadisonMD says:

                @MTR

                don’t think of CBT as a placebo intervention, anymore than I think of driving class as a placebo intervention

                If the effects are intrinsic to CBT, then it is not placebo. However, if a study showed equivalent outcomes of CBT and a control arm (i.e. where you chat with a friend over coffee), then the effects would not be specific to CBT. In that case I would call the effects ‘placebo.’

                So I agree that your interpretation– that CBT is not placebo. However, your footnote implies it is a special case. It is not. Your assessment is entirely consistent with the assessment of acupuncture, education, or any other intervention. To say it works requires the effects to be intrinsic to the intervention.

              7. mousethatroared says:

                darn – MadisonMD – I wrote a response, but I hit the wrong reply link and it threaded in the previous comment. I wish I knew how to link to it, but I don’t. Scroll up if you’re interested.

              8. Andrey Pavlov says:

                I think this discussion about CBT and “placebo CBT” and “works” vs “doesn’t work” can shed some light.

                Finding a placebo for a cardiac drug is much easier since the majority of non-specific interactions will have absolutely zero effect on any objective outcome we may be interested in studying. No matter how charismatic I am, your EF won’t change.

                But when dealing with the brain that is a different story. The reason why some antidepressants were found to be “no better than placebo” in certain cases of depression (very notably not severe depression) is likely to do with confounding of those non-specific effects of the interaction and being in a study to begin with (a Hawthorne effect, but actually a directly acting one!). There are, I believe, multiple lines of evidence to support this idea even though it is not directly rigorously demonstrated. I won’t belabor the post by getting into that.

                The point though is that when the pathology comes from the brain, anything that involves interaction with the brain (which is basically everything) can have a direct and thus non-placebo effect. (Obviously different pathologies will be amenable to different degrees with things like strokes and anoxic brain injury being on the far end of the “doesn’t work well” spectrum, but even then encouragement and non-specific effects probably have some positive effect, likely not clinically relevant, but still worthwhile for psychological well being if not addressing the underlying pathology).

                But how can we scientifically answer the question “does it work?” And why is it that I personally (and I think I am in good company here) say that something doesn’t work if it doesn’t work better than placebo?

                Because when one is trying to understand what “it” is that is working, we need to name that thing. If something – say acupuncture – has the same effect as a placebo then that thing is not what is having the effect! It is everything else about that thing that is having the effect. This is not to deny that there is an effect happening. It is to be scientifically rigorous in stating what “it” is that is having the effect.

                So in the case of CBT we must define it. If it is defined as a rigorously taught set of rhetorical and cognitive tools used by a practitioner and taught to a patient, then we test that. Now, as MTR pointed out, an appropriate placebo is difficult to come by in psychological/psychiatric (a field distinction that I believe will go away once we finally truly accept that dualism is dead and act like it). A depressed person will undoubtedly feel better for having gotten out of the house to have coffee with a friend and this will actually change neural cytoarchitecture and ultimately even neurotransmitter balance. But if CBT shows us the same effect as coffee with a friend, then what we have demonstrated is that the components of CBT that are unique to CBT are not themselves actually efficacious! If coffee with a friend is the same as beer with a stranger is the same as going to an art gallery with a significant other is the same as CBT, then we can say that CBT doesn’t work! Because it is everything else about the CBT that is having a genuine effect, not the CBT itself. Not the extra stuff we are doing in order to practice what is called CBT.

                So the rational course of action (if this were the case) would be to ditch CBT. Or at least note well that the rigorously defined and taught aspects of it are not intrinsically efficacious. We may need less rigorous courses in it, a less rigorous algorithm to follow, less time, money, and resources spent learning to practice it “perfectly” and we may end up with something similar to CBT but with more “bang for the buck” in terms of time vested and outcomes produced.

                The same exact thing applies to acupuncture. It doesn’t work. What everybody and their mom plus their mom’s acupuncturist calls “acupuncture” isn’t actually doing anything. It is everything else about it that is doing it. Which is useful to know! But does not justify the use of acupuncture nor anything less than the clear statement that it doesn’t work.

                Peter is trying to argue that if Air New Zealand gets you to your destination faster and they force you to dance a jig and give you a free can of beer that it must be the jig and the beer getting you there faster when in reality it is that the pilots are goosing the throttle a bit and using a touch more fuel. His defense for this is that the jig and the beer are inseparable from the throttle and thus is can be reasonably said that the jig and beer “work.” In the case of acupuncture he is trying to argue that the specific conditions of acupuncture, including the psychological aspects “knowing” you have something as dramatic as a needle going into your body are necessary for the type and level of non-specific effects to be induced for the effect of acupuncture. And thus “acupuncture works” because without the parts of acupuncture that make it acupuncture you wouldn’t get the “everything else” that is actually having the effect. (I’m pretty sure that is essentially what he is going for – feel free to correct me Peter).

                My issue is that there is no evidence to support his claim, I feel there is plenty to belie the claim, and more to the point there are actual physical risks of harm that obviate the entire conversation. I could also claim that since getting depressed people out and having fun is helpful that doing so at gunpoint would be an efficacious treatment. The surge of adrenalin to react to the gun, the concern that you may die if you don’t listen to me, coupled with the fact that we know catecholamine surges increase neural plasticity (well at least help in the formation of memories, I’lll admit I’m extrapolating a bit beyond the data) and getting out is helpful should make “gunpoint psychotherapy” a technique that “works.” The point being that even if it were demonstrated that the needle penetration is actually a necessary part of eliciting the non-specific effects, it is still not a reasonable method of inducing them (and the toothpick data casts a lot of doubt on the claim in the first place).

                So Peter tries to salvage this by saying that we are redefining acupuncture to some narrow and overly specific thing in order to then make it “not work.” I say that he is defining it overly broadly and in a manner discordant with what acupuncturists themselves call “acupuncture” (and what the lay public thinks as well) in order to define the “everything else” as being a necessary part of “acupuncture” in order to make “acupuncture work” a reasonable statement.

                In any event, hopefully my point is made and reasonably understandable. I think it is perfectly reasonable in every imaginable sense to say that “acupuncture doesn’t work.”

                Oh, and MadisonMD – Peter and I have been at it over acupuncture and placebo for a lot longer than 6 months (I know that’s about how long you’ve been around); more like ~3 years. ;-)

              9. mousethatroared says:

                @ Andrey – I don’t think I have any real disagreement with what you’ve said. I don’t want my doctors to knowingly recommend placebo medicine or therapies (regardless of whether it was an disproven psychological therapy or acupuncture, etc)

                But, I doubt that anyone would have a problem with their doctor recommending a minor lifestyle change that might be considered a placebo (go out for coffee with friends more often in an isolated patient or trying to take time alone to unwind over a book for a stressed patient, ) as long as the patient’s medical needs are being addressed.

                My point, (that probably would go without saying) there’s a difference between a medicalized placebo that encourages a patient’s dependance on a medical service and one that encourages independence or strengthening social/community ties.

                Okay, I sound like I’m preaching, but I’m not, I’m just thinking in type.

          2. PMoran says:

            I refer to interference from other aspects of the trial design, mainly patients being aware that they may be being treated by placebo, but practitioners may also have to avoid aspects of interaction with patients that might interfere with blinding. Practitioners may be unconsciously perfunctory when performing “sham acupuncture”. There is no end to the possibilities.

            This study illustrates some of the problems in measuring placebo/non-specific influences.
            http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2364862/

  29. Joel Dykstra PT says:

    “worthless supplements”

    Even SSR dissed the supplement industry. That’s hilarious.

    1. MadisonMD says:

      Maybe SSR and Stan argue that one ;)

  30. I was trapped in your traditional dream and was just as lost but not as stubborn. Serendipity lead me to expand my views and now it is inclusive of what works for my patients.

    Easy to pillory an unpublished clinical practitioner. My 30 yrs in medicine means nothing. My incorporation of alternative is blasphemy to traditional medicine. My need to find the truth as to why patients failed back and knee surgeries is insulting and unfair to your clan. So shun me so you do not have to expend time and effort rummaging through the data and references that I used to come to this position. Hmmmm?

    Hey I am not trying to elevate myself just because I see a different light. I will keep trying to help. You can really find this info in most text published in the past 10yrs. The innovators were back in the 1930-90s. !! I know what you’re thinking “too old!” But the human physiology, anatomy is set for a long time; surgical procedures like the removal of an appendix will not change so this therapy will not change.

    1. PMoran says:

      “My need to find the truth as to why patients failed back and knee surgeries is insulting and unfair to your clan.”

      SSR, if you are truly helping desperate patients who have not been able to resolve their problems in other ways, that is a wonderful thing. But do remember that you will have a very exaggerated perception of your success rates.

      If you are game, get a neutral person to ring up your ex-patients and ask them for their current opinion and status. I think you would end up a little less cocky if you did that.

      Another feature of medical practice is that practitioners encounter the bad results of other practitioners, but far less of their own — for obvious reasons. You truly will have no idea whatsoever of the success rates and failure rates of the surgical procedures you encounter in your patients.

      If, however, you are referring to ill-judged endoscopic surgery for knee osteoarthritis, and there is a great deal of that going on in your area, then that is something we would not be supporting. The use, or excess use, of certain spinal interventions has also been criticised on these pages.

      1. Stephen S. Rodrigues, MD says:

        One failure is enough to make me pause and, a few hundred should make everyone take notice. The SBM folks are too busy playing their roles dictated by the AMA and big business.

        1. PMoran says:

          “The SBM folks are too busy playing their roles dictated by the AMA
          and big business.”

          Oh, be serious! There are many obvious reasons why people might become deeply and honestly prejudiced against all kinds of CAM without requiring ulterior motives or external urging.

          There is some obvious fraud against seriously ill people. There is the extremely unlikely medical theories. A number of people are harmed by CAM under circumstances where there was never any realistic prospect of benefit. There is a dangerous, anti-mainstream bias that leads to people missing out on beneficial measures including vaccination. CAM includes all these.

          Along with that there is the belief that CAM is has nothing worthwhile to offer which is close to certainty when it comes to the cure or reversal of any disease or disease process.

          I am not so sure when it comes to subjective and psychosomatic complaints in receptive persons, but even therein it would be difficult to replicate such results in general, mainstream, evidence-based medical practice and probably not wise to try.

          So why assume bad faith? I think most of us accept that you are being honest in your beliefs.

          1. mousethatroared says:

            Yes, and they are, coincidentally, the same people who have never done any online dating, never followed craigslist and encourage their children to share their names and addresses with “nice 12 year old boys” they meet online.

          2. mousethatroared says:

            pmoran “I think most of us accept that you are being honest in your beliefs.”

            I guess by “most of us” you mean most of us who have never done any online dating, never followed craigslist and encourage their children to share their names and addresses with “nice 12 year old boys” they meet online.

            1. mousethatroared says:

              doh, sorry for the double post!

    2. WilliamLawrenceUtridge says:

      My 30 yrs in medicine means nothing.

      Absolutely true, for the same reason that the experience of millions of practitioners, for nearly two milennia, who regularly used bloodletting as their primary if not sole therapeutic modality, meant nothing.

      If you can’t demonstrate benefit in well-controlled trials, your experience is not just worthless, it’s harmful.

  31. MadisonMD says:

    You can really find this info in most text published in the past 10yrs.

    Citation please.

    1. Stephen S. Rodrigues, MD says:

      Here is a list of the authors of past and present day who are the primary source for myofascial pain therapy. Myofascial tissue disease is at the core of all complex pain syndromes ie RSD/CRPS

      Intramuscular Stimulation using the techniques of C. Chan Gunn, MD.
      http://www.amazon.com/Gunn-Approach-Treatment-Chronic-Pain/dp/0443054223/ref=la_B0034OMF7A_1_1?s=books&ie=UTF8&qid=1380895970&sr=1-1
      http://www.istop.org/staff.html
      Trigger Point Injections using the techniques of Janet G, Travell, MD, David Simmons, MD
      http://www.amazon.com/Travell-Simons-Myofascial-Pain-Dysfunction/dp/0683307711/ref=sr_1_1?s=books&ie=UTF8&qid=1380896055&sr=1-1&keywords=janet+travell
      Myofascial Pain and Fibromyalgia, Edward Rachlin, MD.
      http://www.amazon.com/Myofascial-Pain-Fibromyalgia-Trigger-Management/dp/0323011551/ref=sr_1_2?s=books&ie=UTF8&qid=1380896116&sr=1-2&keywords=Rachlin+edward
      Ligament and tendon relaxation techniques of George Stuart Hackett, MD.
      http://www.amazon.com/Ligament-Tendon-Relaxation-Treated-Prolotherapy/dp/B002AOC46M/ref=sr_1_1?ie=UTF8&qid=1386548589&sr=8-1&keywords=George+Stuart+Hackett%2C+MD.
      Backache from Occiput to Coccyx by Gerald L. Burke (Hardcover – 1964) http://www.amazon.com/Backache-Occiput-Coccyx-Gerald-Burke/product-reviews/B000RB66LY/ref=dp_top_cm_cr_acr_txt?showViewpoints=1
      CraigPENS as per William F Craig, M.D.
      http://www.anesthesiologynews.com/ViewArticle.aspx?d_id=2&a_id=10480
      Myofascial Release by Gokavi, Cynthia N. Gokavi, MBBS.
      The Trigger Point Therapy Workbook: Your Self-Treatment Guide for Pain Relief, Second Edition by Clair Davies, Amber Davies and David G. Simons (Aug 1, 2004)
      Fibromyalgia and Chronic Myofascial Pain: A Survival Manual (2nd Edition) by Devin J. Starlanyl and Mary Ellen Copeland (Jun 30, 2001)
      http://www.amazon.com/Healing-through-Trigger-Point-Therapy/dp/1583946098/ref=sr_1_1?s=books&ie=UTF8&qid=1380896220&sr=1-1&keywords=Devin+J.+Starlanyl
      http://homepages.sover.net/~devstar/
      Advanced Soft Tissue Techniques as per Leon Chaitow, ND, DO
      Medical Acupuncture as per French Energetic protocols of Joseph Helms, MD.

      1. windriven says:

        Are you effing kidding, Rodrigues? The closest you come to an actual journal citation is anesthesiology news – essentially an aggregator of news releases?

        You really need to give your head a shake.

  32. PMoran says:

    Andrey: “Does that settle it? Can we agree on that and just move on?”

    I can agree with many of those points, but I don’t approve of the fact that you still want to have it all ways.

    You assert with even more certainty than I can recall expressing that the effects under discussion “are real and can be quite profound in very specific cases” while still reserving the right to totally disregard the phenomenon (as ” — angels dancing on the head of a pin”). That is inconsistent with the duties of practical medicine or its science..

    You also still wish to use a shifting meaning to the word “placebo” so that it can include the wide variety of potentially therapeutic influences that may be exerted during a program of acupuncture (which might include a tad of inadvertent CBT or “support group” psychosocial kinds of activity). There is no evidence-based procedure that would mimic such a spectrum of influences. CBT itself requires a fair amount of patient intelligence and insight, also a willingness to participate over a considerable time in a purely “talk” arrangement. Many patients will resist that .

    We have not yet delved deeply into what “placebo” means but it is actually as inconveniently grey an area as almost anything else within medicine once you start to use the word in different settings.

    1. Andrey Pavlov says:

      but I don’t approve of the fact that you still want to have it all ways

      I want it however the data shows it to be. That may be “all ways” to some, I suppose.

      You assert with even more certainty than I can recall expressing that the effects under discussion “are real and can be quite profound in very specific cases” while still reserving the right to totally disregard the phenomenon (as ” — angels dancing on the head of a pin”). That is inconsistent with the duties of practical medicine or its science

      I’ve explained why. I can also agree that magnetic monopoles are demonstrated to be true in nature but so exotic and so rare as to disregard them for all practical purposes. Understanding that the phenomenon exists is useful for informing future research and may yield potential applications, but not yet. I might also agree that Xigris actually did help the occasional person with a particular Protein C polymorphism, but that doesn’t mean I now need to devote a billion dollars and countless hours to find out who those rare few may be.

      You’ve ignored everything else I have written about how the argument could be exactly the same for faith healing, reiki, snake handling, and homeopathy. Yet you seem perfectly comfortable completely discounting them.

      You also still wish to use a shifting meaning to the word “placebo” so that it can include the wide variety of potentially therapeutic influences that may be exerted during a program of acupuncture

      No, I don’t. I’ve been pretty precise with my usage even to the point of studiously differentiating placebo “responses” from placebo “effects.”

      which might include a tad of inadvertent CBT or “support group” psychosocial kinds of activity

      Those are not placebo but are, in reality, direct effects as I commented to MTR earlier today.

      There is no evidence-based procedure that would mimic such a spectrum of influences.

      And this is where our fundamental difference may lay. This is an evidence-free statement. It is merely your hypothetical assertion based on just-so stories about what you think acupuncture is (or could be). And, furthermore, I could say the exact same thing about homeopathy (once again). You seem pretty happy to dismiss homeopathy. Heck, I would argue homeopathy is likely to have even more CBT-type influences than acupuncture.

      Are you about to claim you have some even remotely rigorous way of delimiting, let alone quantifying, all these effects such that you can actually make that statement? If so, evidence please. Because a lot of my patient interactions involve a lot of those non-specific influences and I do take time to provide my patients counseling on how to cope and manage their illness.

      No Peter, this is where you leave the realm of scientific rigor and legitimacy by claiming much more about acupuncture than the data demonstrates based on nothing more than your own particular penchant for it.

      CBT itself requires a fair amount of patient intelligence and insight, also a willingness to participate over a considerable time in a purely “talk” arrangement. Many patients will resist that .

      But somehow this is done in an acupuncture session? And in a manner completely unassailable by evidence based practices? Bollocks.

      We have not yet delved deeply into what “placebo” means but it is actually as inconveniently grey an area as almost anything else within medicine once you start to use the word in different settings.

      Wow. I must have been exchanging tomes with a different Peter Moran then, because we most certainly have delved deeply into what placebo means.

      YOu also made a comment elsewhere:

      Along with that there is the belief that CAM is has nothing worthwhile to offer which is close to certainty when it comes to the cure or reversal of any disease or disease process.

      I am not so sure when it comes to subjective and psychosomatic complaints in receptive persons, but even therein it would be difficult to replicate such results in general, mainstream, evidence-based medical practice and probably not wise to try.

      Yes, one of the points here – that I agree with – is that by definition CAM cannot have anything worthwhile to offer for anything. Because CAM is either that which is yet to be investigated or that which is disproven. All else is simply medicine. And that which has yet to be tested has a well established a priori likelihood of being worthwhile – very low.

  33. Stephen S. Rodrigues, MD says:

    I figured since this site and others by the contributors are making such bold statements about “Acupuncture doesn’t work”, that I have to change or update this assertion. Because it’s not true and actually is an outright lie.

    The blog lends itself to a groupthink mentality that is obvious! Everyone is quite sycophantic and not independent thinkers or researchers.
    NO investigating, acquiring new knowledge, updating or clarifying of knowledge.
    A single method of acquiring data; using old flawed research that was erroneously collected and interpreted.
    How can you make such a statement about a discipline if you have never observed or experimented a therapy.

    Did anyone check out the textbooks or just decided to sit on your present achievements.

    1. MadisonMD says:

      @SSR: What in the world are you talking about? Why are you so lazy as to not read or think about the posts here? You say that all are sycophantic and there is no independent thought. The most cursory review of the comments here reveal you are wrong.

      There have been dozens and dozens of posts between Dr. Moran, Dr. Pavlov and others arguing about the statement “Acupuncture doesn’t work” spanning 6 months or more. Citations were provided. Data were reviewed. The data are not in dispute– there is little, if any, specific effect of acupuncture. The only dispute is whether the nonspecific ‘placebo’ effect counts as ‘works.’

      The fact that everyone– including both Dr. Moran and Dr. Pavlov– disagree with you does not mean that they are sycophants, obviously!. What it means is you lack convincing, rational, and comprehensible arguments for your extreme position… and your posts reveal that you are oblivious and indifferent to your ignorance.

  34. Peter s. says:

    Perhaps some would dismiss it as placebo, or anecdotal, or both, but from my reading a tremendous number of people seem to have conquered chronic back, neck and other pain (mostly but not necessarily limited to muscle tension type pain) using mind-body approaches such as those of Dr. John Sarno.

    1. Harriet Hall says:

      And a lot of people recovered from chronic back, neck and other pain without any treatment, due to the natural course of the disease. I don’t dismiss your report as placebo or anecdotal, but I do ask for evidence from controlled studies.

  35. RE: Neuroscience should prove that “placebo medicine” is no fluke, as it has root causes and effects at our “autonomous” or “subconscious” level, that the present-day (prevalently physicalist) scientific method and thinking have yet been able to identify, characterize, or quantify!?

    It’s time to move past the empty rhetoric and deceptive shell-game of “placebo medicine.” Non-specific effects of a positive therapeutic intervention, combined with specific psychological interventions, can reduce the experience of pain and improve quality of life. This should not be used to justify useless rituals and the magical thinking (and risks, however small) that go along with them.

    Rather, researchers interested in such effects should study them directly and figure out how to maximize their usefulness and free them from the pre-scientific rituals in which they are often embedded.

    Preamble: In a rather broad stroke of concluding remarks (as quoted above): I thought that Steve Novella has had unknowingly revealed himself to be an “under-informed” or physicalist critic of SBM, particularly on matters such as the “placebo medicine” (PM) vs Acupuncture (ACM or ancient Chinese medicine-philosophy) issues, and the East-West (non-physicalist) biomedical scholarship, in general!?

    Comment: Neuropsychologically, ACM — particularly Acupuncture — is not a collection of non-specific effects of a positive therapeutic intervention, that has had privileged on some useless or undefined needling rituals, and/or moxibustion. The modern-day PM research and design shall not be totally divorced from the pre-scientific (non-physicalist) notion of ritualism that is inherent in ACM literary scholarship and practice; and, today’s erudite (holistic) biomedical researchers-scientists must incorporate the essence of ritualism or spiritualism into their empiricist plans of attack or interrogation in their concurrent PM investigations!? Otherwise, the physicalist inclined researchers will soon lose their own non-physicalist scientific objectivity and sensitivity in their continuing pursuit or in search of a “holistic medicine” since Hippocrates!?

    While developing almost in parallel to the Hippocratic holistic biomedical principles and practice, the ACM was not created — especially based on the prevailing Western physicalist scientific thinking since the 17th century past — but ACM was created, allegorized, philosophized, intuited, and based on the prevalent “flow” or “spirit” or “principle” of Daoism (circa 500 BCE), an ancient Chinese philosophy of “change” and “adaptation” of “human nature” to the Nature, especially the human internal cosmic matters concerning and practicing their livelihoods as related to “health” or “disease” or “dis-ease” just as those Hippocratic holistic terms that have had been and are still being biotechnologically and biomedically defined, and refined, in our modern neuropsychiatry, neuropsychology, neurophysiology, and related research and development issues, since the 1980s!?

    Although primarily based on the pre-scientific non-physicalist Daoist natural philosophy, phenomenology, specifically corporeal observations, mental intuitions, empathetic treatments, causes and effects, etc (real and imagined; physical and mental; or otherwise “yin and yang” issues, etc), the theory of Acupuncture was first fully developed, illustrated, and recorded in writings, by the 2nd century BCE. The ACM has had since been popularized and practiced in China and elsewhere worldwide, while without been subject to any of the modern-day SBM-RCTs, at all. This is because most ACMs are characterized and qualified as non-invasive or herbal or supplemental medicines (such as, the Western pre-scientific notion of naturopathic, chiropractic, osteopathic; Hindu yoga, etc) — except in the case of Acupuncture: which has had been singled out and labeled as a “deceptive” PM, as Novella has tried to characterize above!?

    Whereas by modern biomedical definition and comprehension — or apprehension and rejection as in the Novella Acupuncture case — I would venture that Acupuncture per se can and shall be proved that it is not a “shell-game of PM” or fluke, as one that has exclusively engaged in needling ritualism, as Novella has clearly asserted above!? Furthermore, I would double down so as to affirm that Acupuncture in ACM not only involves non-physicalist ritualism; it also invokes both the “specific” local and “autonomous” central nervous systems, or the parasympathetic and sympathetic nervous systems, as well!?

    Conclusion: Thus, future competent or holistic-inclined biomedical researchers, scientists, acupuncturists, neurophysiologists, etc interested in such “real” PM effects, should diligently design, investigate, and integrate the fact that How Acupuncture and its specific needling rituals, could “actually” invoke both the sympathetic and parasympathetic neurophysiology so as to attain a “real” or “imagined” PM neuropsychology — as one that could be detected in the modern fMRIs!?

    Consequently, this is Why and How Acupuncture (in so many cases) has had been used to treat pain “neuropsychologically” (via invoking ritualism or spiritualism so as to calm the nerves and/or dull pain) — as well as locally or physically (via needling maneuvers so as to elicit local analgesia or endorphins, if any — noting that ACM is not an exact neuroscience nor neuroanatomy, at all) — meaningfully, satisfactorily, and successfully (via invoking or priming our subconscious or autonomous neuroendocrine pathways to dull or calm pain, etc): as all these observations and practice, that the SBM reader Stephen Rodrigues, might have had experienced in his office on any workday!?

    Best wishes, Mong 3/1/14usct3:58p; practical science-philosophy critic; author “Decoding Scientism” and “Consciousness & the Subconscious” (works in progress since July 2007), Gods, Genes, Conscience (iUniverse; 2006) and Gods, Genes, Conscience: Global Dialogues Now (blogging avidly since 2006).

  36. WilliamLawrenceUtridge says:

    Hi Dr. Tan,

    1) China has an amazing history. Its size, population and technological dominance of the world for centuries, if not millennia, is astonishing and impressive. That being said, when it came to medical knowledge, they were wrong. Dead wrong. They lacked the tools to understand the cellular nature of human tissues and the microscopic nature of infectious disease. There is no reason to grant them special knowledge or abilities when it comes to understanding the microscopic nature of life.

    2) Attempting to defend TCM, moxibustion and acupuncture on the basis of “ritual” and “nonphysicalism” rather misses the point. We know that none works. We know that the botanical preparations of TCM (and in particular, the hideously wasteful and cruel animal preparations) are essentially worthless, particularly compared to modern medications. We know acupuncture doesn’t work, according to its strict precepts (there is no “energy” manipulated, acupuncture points don’t matter, it doesn’t matter f you penetrate the skin, and the anatomical assumptions are flat-out wrong). The diagnostic process is irrational, imaginary and meaningless, feeding into a worthless diagnostic nosology. Given that empirically we can see TCM and acupuncture don’t do what they proclaim to do, theorizing about how they work rather misses the point.

    3) Defending TCM because “it was developed at the same time as Hippocrates system” misses an obvious point – Hippocrates was pretty much wrong as well, except for what we could call “lifestyle interventions” that are ultimately pretty obvious. “Holism” is a meaningless term used for marketing purposes, particularly given doctors are “holistic” already. They may not give spiritual counseling, but given the fact that there is no proof that “spirit” exists, and given how worthless priests were in treating illness through “spiritual” counseling, this isn’t exactly a loss. A lot of quacks and alternative practitioners bleat about the importance of “spirit”, mostly because doctors have to restrict themselves to reality while quacks will latch onto anything to make themselves look different, as if they added something to medical practice that wasn’t redundant or worthless.

    4) Daoism may be a great philosophy for interpersonal interaction and establishing harmonious governments, but it’s worthless as a medical system.

    Anyway, that’s a lot of highfalutin words and bloviation to basically say “it’s right because it’s old”. Attempting to investigate how something works when we know it doesn’t work is the essence of Tooth Fairy Science. Please feel free to laugh yourself out of the comments section.

    Also, please don’t encourage Steve Roddy, he’s an idiot.

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