Acupuncture Does Nothing

Acupuncture Does Nothing

Those who routinely read my essays over at Science-Based Medicine are no doubt aware that I do not think much of the placebo effect, at least as a useful modality for the treatment of patients.

Placebo is a critical component in clinical trials and understanding how it works is important since placebo effects are an important adjunct to real medicines.

But most of the pseudo-medicines, since they do nothing, get all their alleged benefit from placebo effects. In clinical trials, if treatment effects are no better than placebo, it is reasonable to conclude that the treatment does nothing. Placebo, then, does nothing, certainly for objective endpoints.

Subjective endpoints, like pain, are trickier. In the slang of medicine we say that pain has a supratentorial component. Expectations and attitude can markedly alter the perception of pain. The stimulus for the pain does not change, but the perception of the pain can be modified. At one perspective you could say that if perception of pain is changed then the pain is changed, even it is due to placebo effects.

The best example, which I think nicely summarizes that particular aspect of placebo, is kissing your childs skinned knee. The child believes it to be better and is comforted. The problem with using placebo as a primary medical intervention is that it requires lying to the patient to get an effect. You have to believe that placebo is effective to get effects. You cannot get placebo effects without deception and as a result is not ethical to use outside of studies.

It is safe to say that acupunctures do nothing beyond placebo. Most studies suggest that the main factors in having a positive effect for pain from acupunctures is thinking you received acupuncture and believing you will have an effect from the intervention. Acupunctures are at their core medical theater.

Responding to placebo has two components: expectation and conditioning. These aspects of placebo were evaluated in a study, Expectancy and Conditioning in Placebo Analgesia: Separate or Connected Processes?

In it they used both acupunctures and sham acupunctures (actually they picked electro-acupuncture from the numerous forms of acupuncture) to tease the placebo response to pain from expectation and conditioning. In a interesting twist, the patients were told a 'lie,' that is actually the truth:

Participants in both groups were misinformed that the acupuncture treatment would affect one side of their arm but not the other. Because a genuine acupuncture effect would not be specific to a randomly selected side of the arm, any difference in pain between the “treated” and the “untreated” side would be a placebo effect.

The patients were deceived and a belief in that deception, that acupuncture has a genuine effect, is evidently part of the researcher bias. There is no genuine acupuncture effect and I snorted when I read that.

It is a turgid article, and if indicative of the writing in the Psychologic literature, I will stick with medicine. It is rare to read an article that is so unclear even on repeated readings, but I think I understand it. Its major conclusions had to do with the relative effects of conditioning and expectation in pain perception and that both were active.

There were no significant main effects or interactions associated with type of acupuncture (real vs. sham). In both groups, conditioning decreased expected pain for “treated” location and also increased the placebo effect (i.e., the difference in pain report between “treated” and “untreated” locations). In addition, mediation analysis lent support to the hypothesis that the effects of conditioning on placebo analgesia may be mediated by expectancy, although the size of this indirect effect requires further study.

More curious from an SBM perspective is that the article confirms that there is no genuine acupuncture effect, although that is not discussed. The effects on pain of sham and real acupuncture were the same kissing the boo-boo. The effects depended on the expectations of the patient. It would be interesting to have a wing where the subjects, preferably participants recruited from TAM, were told that acupuncture is useless and were told of the conditioning. I suspect acupuncture would have no effect at all.

You could argue that a decrease in the perception of pain is a real effect, since we do not have a pain-o-meter to independently measure the amount of pain the patient experiences. I would not disagree. Having patients change their perception of their illness can be important to the quality of their life even if it does nothing objective to their illness. The problem remains that in order to get this effect from pseudo-medicines it requires a lie. As another put it

Herein lies the problem. Central to the practice of medicine is the concept of informed consent; that patients must agree, and fully understand their treatment options. This is of paramount importance – medical treatments can be complex and can result in large impacts on a patient’s quality of life. To fully benefit from alternative medicine, we’d have to return to a paternalistic model of medicine, where we forewent autonomy in our medical care.

The dangers of such an arcane healthcare system are widespread. Lessons from history, such as experiments conducted without seeking the permission of the participants, or the practice of lobotomy, an outdated treatment justified by fabricated evidence, illustrate the importance of transparency and accountability in healthcare. More recent scandals, such as the disaster at the Mid Staffordshire NHS Trust, further highlight the importance of such ethical standards. To surrender these principles would be foolish - it is crucial that patients are free to question their diagnosis and treatment. After all, it is only when we understand a treatment option that we can ever truly consent to it.

This is the paradox of alternative medicine; by understanding, we render the treatment ineffective. Yet by concealing medical knowledge, we return to a dangerous, medieval-like approach to healthcare. It is for this reason why alternative medicine is flawed. As tempting as it might be to embrace placebo-based treatments, the ethical standards we would have to sacrifice are infinitely more valuable.

So while these studies elucidating the mechanism of placebo are interesting, they further diminish the ethical rationale of pseudo-medicines in real medical practice.

Points of Interest 8/16/2014
Points of Interest 8/15/2014