As a doctor, I didn’t think much of acupuncture. Then the opioid crisis arrived

As a doctor, I didn’t think much of acupuncture. Then the opioid crisis arrived

When patients used to ask me if there were any supplements, vitamins, oils, or other alternative therapies that they should be using to manage their pain, the message was simple: “Not really,” I told them, “Unfortunately there isn’t any good evidence for that stuff.” In my examination room, like thousands of others across the Western world, the “pain ladder” reigned supreme. But in the midst of an opioid epidemic that’s killing by the thousands, and bearing in mind that there’s some evidence for acupuncture, when does our compassion and our oath as physicians to “do no harm” trump the status quo?

In December, the American Pain Society endorsed the use of acupuncture for chronic pain, suggesting that this ancient technique could be part of a new, holistic approach within the context of Western medicine. When a frustrated patient, walking the dark path toward opioid addiction, asks me if they should try acupuncture, at least now I can tell them it’s worth a shot.

As a doctor, I didn’t think much of acupuncture. Then the opioid crisis arrived

As far as I can tell there appear to be blinding issues with the main study he references - beware ‘pragmatic’ studies. The weight of evidence is against acupuncture:

https://theness.com/neurologicablog/inde...in-the-ed/

[Laird]

You may have a point, malf, but don't needle Sci. You're not easing his pain.

You may have a point, malf, but don't needle Sci. You're not easing his pain.

Oh bravo!

As a doctor, I didn’t think much of acupuncture. Then the opioid crisis arrived

The author describes his own experience of feeling better as he left the therapy session. What was missing was any mention of how he felt the following day, the following week...

I know sometimes I've felt better after a visit to the doctor even when I knew from experience that the prescription I'd just been given was useless. Simple human contact itself can be therapeutic.

My experience with acupuncture has been amazing, and no, there was no "placebo effect". It was from crushing pain to no pain at all, and not once, but many times. Not only with me, but many students of mine with profession-related hand problems to whom I recommended my acupuncturist had the same amazing results. So, when somebody tells me acupuncture doesn't work, I just laugh.

My experience with acupuncture has been amazing, and no, there was no "placebo effect". It was from crushing pain to no pain at all, and not once, but many times. Not only with me, but many students of mine with profession-related hand problems to whom I recommended my acupuncturist had the same amazing results. So, when somebody tells me acupuncture doesn't work, I just laugh.

Tell me, Enrique: I've often thought of trying acupuncture, but some acupuncturists must be better than others. How does one go about finding the best?

As far as I can tell there appear to be blinding issues with the main study he references - beware ‘pragmatic’ studies. The weight of evidence is against acupuncture:

https://theness.com/neurologicablog/inde...in-the-ed/

That link leads to an article by Steven Novella, citing an invited "Con Editorial" in a journal also co-written by Novella (that means the authors were invited to write an article specifically arguing the case against acupuncture, in response to another invited article in favour). From a quick look at what Novella writes, the arguments about acupuncture sound very much like the arguments about psi.

The trouble is that I've read so much poor-quality sceptical argument against psi (including from Novella), that it makes me more cautious than I would otherwise be to accept the criticisms of acupuncture on trust.

And as for what Novella is actually telling us, his online article begins:
"Acupuncture still doesn’t work. We have thousands of studies collectively showing that it does not matter where you stick the needles or even if you stick the needles. Acupuncture is an elaborate placebo, and nothing else."

The two statements I put in bold are actually quite different, because placebos can work, and can work quite powerfully. Which does he really mean?

The invited editorial is actually entitled "Acupuncture Is Theatrical Placebo":
https://journals.lww.com/anesthesia-anal...bo.25.aspx

On the question of whether acupuncture works as a placebo, the editorial says:
"If, indeed, sham acupuncture is no different from real acupuncture, the apparent improvement that may be seen after acupuncture is merely a placebo effect. Furthermore, it shows that the idea of meridians is purely imaginary. All that remains to be discussed is whether or not the placebo effect is big enough to be useful, and whether it is ethical to prescribe placebos."

The authors dismiss the effectiveness of acupuncture for a number of conditions, but acknowledge that for one condition, post-operative nausea and vomiting, "The meta-analysis showed, on average, similar effectiveness for acupuncture and antiemetic drugs".

That sounds like a big enough placebo effect to be useful, but they immediately follow that by saying that the effectiveness of one of the conventional drugs in the comparison, metoclopramide, was itself in doubt. The trouble with that argument is that metoclopramide was only one of six drugs compared with acupuncture (5 studies out of 40 in the meta-analysis), and according to the figures cited in the "Pro editorial" it was already known to be one of the least effective. The meta-analysis is here:
http://cochranelibrary-wiley.com/doi/10.....pub4/full

The authors have also gone through the quality assessments in the meta-analysis and highlight some that they consider represent possible sources of bias. Based on the quality of the studies, they say that "perhaps the conclusion [of the meta-analysis] should have been “more research needed.” "

Of course, there can also be a risk of bias when a committed sceptic assesses the evidence for a phenomenon he is convinced is spurious. But the trouble is that, even accepting that assessment at face value, there is a big difference between what Novella and his co-author say in the journal editorial, and what Novella says in his blog article. aimed at a popular audience. In the journal, we have a critical discussion of a meta-analysis showing that acupuncture is as effective as conventional drugs for a particular condition, resulting in a conclusion of "more research needed". But in the blog article aimed at a popular audience, we have this:
"Acupuncture still doesn’t work. ... We are definitely way past the point (thousands of studies over several decades) to conclude that acupuncture is a lost cause."

On the whole, that makes me rather less inclined than I was to trust Novella's statements about anything.

I think maybe this is one area where direct personal experience trumps statistics. I have had astonishing results from acupuncture, for a condition that I was told would probably need surgery, and which recurred a couple of years later and was fixed immediately by a different acupuncturist. I have had other problems that it didn’t help with.

I understand the importance of medical trials and analysis but as a complementary therapy I cannot see the harm in trying it especially if the conventional treatments are too drastic or don’t give sufficient probably of success. There are lots of complementary techniques that help with pain control that don’t involve codeine or other powerful drugs. They’re not always as immediate or easy as popping a pill alas.

That link leads to an article by Steven Novella, citing an invited "Con Editorial" in a journal also co-written by Novella (that means the authors were invited to write an article specifically arguing the case against acupuncture, in response to another invited article in favour). From a quick look at what Novella writes, the arguments about acupuncture sound very much like the arguments about psi.

The trouble is that I've read so much poor-quality sceptical argument against psi (including from Novella), that it makes me more cautious than I would otherwise be to accept the criticisms of acupuncture on trust.

And as for what Novella is actually telling us, his online article begins:
"Acupuncture still doesn’t work. We have thousands of studies collectively showing that it does not matter where you stick the needles or even if you stick the needles. Acupuncture is an elaborate placebo, and nothing else."

The two statements I put in bold are actually quite different, because placebos can work, and can work quite powerfully. Which does he really mean?

The invited editorial is actually entitled "Acupuncture Is Theatrical Placebo":
https://journals.lww.com/anesthesia-anal...bo.25.aspx

On the question of whether acupuncture works as a placebo, the editorial says:
"If, indeed, sham acupuncture is no different from real acupuncture, the apparent improvement that may be seen after acupuncture is merely a placebo effect. Furthermore, it shows that the idea of meridians is purely imaginary. All that remains to be discussed is whether or not the placebo effect is big enough to be useful, and whether it is ethical to prescribe placebos."

The authors dismiss the effectiveness of acupuncture for a number of conditions, but acknowledge that for one condition, post-operative nausea and vomiting, "The meta-analysis showed, on average, similar effectiveness for acupuncture and antiemetic drugs".

That sounds like a big enough placebo effect to be useful, but they immediately follow that by saying that the effectiveness of one of the conventional drugs in the comparison, metoclopramide, was itself in doubt. The trouble with that argument is that metoclopramide was only one of six drugs compared with acupuncture (5 studies out of 40 in the meta-analysis), and according to the figures cited in the "Pro editorial" it was already known to be one of the least effective. The meta-analysis is here:
http://cochranelibrary-wiley.com/doi/10.....pub4/full

The authors have also gone through the quality assessments in the meta-analysis and highlight some that they consider represent possible sources of bias. Based on the quality of the studies, they say that "perhaps the conclusion [of the meta-analysis] should have been “more research needed.” "

Of course, there can also be a risk of bias when a committed sceptic assesses the evidence for a phenomenon he is convinced is spurious. But the trouble is that, even accepting that assessment at face value, there is a big difference between what Novella and his co-author say in the journal editorial, and what Novella says in his blog article. aimed at a popular audience. In the journal, we have a critical discussion of a meta-analysis showing that acupuncture is as effective as conventional drugs for a particular condition, resulting in a conclusion of "more research needed". But in the blog article aimed at a popular audience, we have this:
"Acupuncture still doesn’t work. ... We are definitely way past the point (thousands of studies over several decades) to conclude that acupuncture is a lost cause."

On the whole, that makes me rather less inclined than I was to trust Novella's statements about anything.

In medicine whether something ‘works’ refers to whether it outperforms placebo.