I once made the mistake of expressing doubts about acupuncture to a friend who was a “true believer”. Like all true believers, there was an almost religious fervor in his testimonial. After all, he personally experienced relief of his low-back pain, lasting 3 days! How could I, armed with all the scientific data but no personal experience, doubt him? I am happy to report that we are still friends.
What do we mean when we say a treatment works?
The conversation caused me to think about the more fundamental question of what do we mean when we say a treatment “works”? When I look at results of a drug trial and I see that the experimental arm is no better than the control, both show a 30% effect (or 50% in psychiatric drug trials). The conclusion is clear-cut: the experimental arm is no better than the placebo. The drug doesn’t work. But if you ask some of the people in the experimental arm who experienced an effect, they will swear up and down that the drug does work. So who is right?
Unlike the common perception, the placebo effect is not “all in your head” because you are gullible, or suggestible, or worse. It is literally in your head. Many studies have clearly demonstrated that chemicals in the brain, such as endorphins, dopamine, endogenous cannabinoids (as in cannabis, the active ingredient in marijuana), are major factors in the placebo effect.
So, does acupuncture work?
In September 2012, a study was published in the online edition of the Archives of Internal Medicine which ostensibly showed that acupuncture works in the “scientific” sense of the word, namely that it is superior to placebo. But barely.
The authors, who include researchers with Memorial Sloan-Kettering Cancer Center in New York and several universities in England and Germany, conducted a meta-analysis of the best available studies that had been published on the subject. They examined 29 studies involving almost 18,000 adults and meticulously went through the individual charts of the patients.
Meta-analysis is not as robust a method as a randomized, double-blind, controlled study design. But, in this study, the large number of patients involved, the careful accounting for confounding factors, and the painstaking examination of individual patient data make this study pretty good.
As to the results, the difference between the acupuncture group and regular treatment (no acupuncture) was very large in favor of acupuncture. But this comparison does not address the main question: What is “real” and what is the placebo? This can be done only by comparing acupuncture and sham treatment with needles that resembles acupuncture but isn’t the real thing.
Here the picture is less clear; acupuncture was better than a sham, but only barely. And given the difficulty of accounting for all possible confounding factors, it is impossible to state with confidence that acupuncture is anything more than a placebo.
What about the patient?
But this is the “scientific” conclusion. What about the patient? After all, patients are what medicine is all about.
Here is the author’s conclusion:
“Acupuncture is effective for the treatment of chronic pain and is, therefore, a reasonable referral option. Significant differences between true and sham acupuncture indicate that acupuncture is more than a placebo. However, these differences are relatively modest, suggesting that factors in addition to the specific effects of needling are important contributors to the therapeutic effects of acupuncture”
The key words here are “reasonable referral option.” This is revolutionary. What it means is that even though the benefit of acupuncture is slight to non-existent from a strictly scientific view, who cares? The patient’s outcome is the measure. If there is pain relief, we should not deprive him or her of the benefit just because the mechanism is either unknown or is due to placebo effects on the brain.
Learning from the past
I find it ironic that until the 18th century (the age of enlightenment and invention of the scientific method), placebo was the main mode of therapy. Think of a physician holding the hand of the bedridden patient, a subject of many artworks, such as Sir Luke Fildes, 1887 painting, “The Doctor”.
Plant extracts, potions, voodoo—these were the only tools available since the ancient civilizations of Egypt, Mesopotamia, the Indus Valley, and China. Maybe we should go back and reexamine the clay tablets, hieroglyphs, Hindu Vedas, and Chinese parchment manuscripts. There may be great wisdom in them thar writings.
I was struck by how timely it is now as the patient centricity has moved to the forefront of medical thinking. I welcome your comments. -Dov