The flagship journal of my specialty of family medicine is the American Family Physician. Each issue contains a quiz that qualifies for continuing medical education credit (CME). I have long relied on it to keep me up to date, and its information is generally trustworthy. So far it has not promoted alternative medicine, but there have been occasional lapses. I have written several letters to the editor, two of which were published and are listed in PubMed, on the GAIT trial of glucosamine and chondroitin and on the poor evidence for green tea. In both cases, the authors replied, made excuses, and failed to adequately address the points I raised; so I wonder if my letters did more harm than good.
My heart sank when I saw that the current issue (July 15, 2019) featured an article on Acupuncture for Pain. It annoyed me enough that I felt compelled to try again. I wrote a letter to the editor, but I will not be surprised if they decide not to publish it. Standing up for rigorous science and reason is not popular, and many MDs lack an understanding of the many ways studies can produce false results. They may think any positive study is good “evidence”. I think that’s what happened here. The authors found plenty of evidence to confirm their belief that acupuncture is effective for pain. They failed to appreciate that much of that positive evidence was flawed. They didn’t seek out negative evidence that contradicted their beliefs. They said acupuncture was safe and effective. And AFP compounded the error with an editorial in the same issue on Integrating Medical Acupuncture into Family Medicine Practice that discusses strategies for convincing doctors and patients that acupuncture is effective and recommends family physicians be trained in it.
The evidence described in the article
They describe measurable effects on the nervous system like functional magnetic resonance imaging and the release of endogenous opioids. They do not mention that similar findings are seen with placebo responses. They say the mechanism of action is “likely not completely known”. In my opinion, it is known: it’s called the placebo response.
They explain that acupuncture research is problematic due to the difficulty of credible blinding and the heterogeneity of acupuncture practices. They admit “most of the evidence is low or moderate quality”. But they go on to cite low quality evidence for low back pain, knee osteoarthritis, headaches, neck pain, fibromyalgia, and post-operative pain (although they do mention that most of those studies are small and at risk of bias).
They cite studies showing that acupuncture is safe. They say no serious events such as hospital admission, permanent disability, or death have occurred. That’s demonstrably false. Several deaths have been reported in the literature, as have hospitalizations to treat pneumothorax and to surgically remove acupuncture needles that have migrated and caused complications like cardiac tamponade. They cite systematic reviews that support their thesis but fail to cite Edzard Ernst’s systematic review of systematic reviews that found a mix of negative, positive, and inconclusive results and found only one case where more than one systematic review reached a positive conclusion. For neck pain. Is there any other pain treatment that works for pain in the neck but not in any other part of the body?
They conclude that acupuncture may “work” only because of “patient expectations, the treatment ritual, the therapeutic interaction with the acupuncturist, and other aspects of the placebo response”. They essentially agree with Colquhoun and Novella that acupuncture is a theatrical placebo. And they cite the asthma study where patients had subjective but not objective improvements. Despite all this, they recommend acupuncture. Medical ethicists reject the use of placebos in clinical practice as unethical.
In my opinion, the article is biased, incomplete, gives false information, and is unethical. You can read the whole article online and form your own opinion.
The accompanying editorial recommends quack-speak
In my opinion, the editorial is despicable. It gives these examples of suggested language designed to persuade patients:
- “I think acupuncture may help you. I’ve noticed in my own patients that it seems pretty beneficial. Eighty percent of my patients get better with acupuncture or have a positive response.”
- “There are more options available, but I recommend acupuncture. I use it on myself and my family to try to help with pain and discomfort.”
- “Acupuncture is ideal for avoiding adverse effects of medications and returning people to work without impairment.”
- “This is a treatment where we just try to center your thoughts around calmness.”
- “These are strong [acu-]points. These are more powerful points.”
- “The acupuncture treatment is going to help settle your body and your mind.”
- “If you get any response, that’s good. Eventually, I want to get you spaced out to three to four months, so you’re coming in for a maintenance treatment.”
- “Acupuncture is like unlocking a door. To unlock a locked door, first you have to pick up the key. That’s your first appointment. Then you have to actually move toward the door, and that’s your second treatment. You have to put the key in the door. That’s your third treatment. Turn it, fourth; turn the handle, fifth; open the door, sixth; walk through, seventh. That’s how acupuncture works—you’re not going to see one treatment be a miracle. It’s a stepwise process.”
- “You’ve been out of balance for awhile, and it feels uncomfortable to try and push you back into that equilibrium. That’s okay if you feel bad for the first couple of days. It will get better. Any kind of a change is a good sign, because it means that we did something to activate that and to improve that.”
Does all that sound familiar? It should. It is not the language of science. It could have been taken directly from the playbooks of many a quack and charlatan.
Conclusion: AFP erred
The AFP is wrong. Acupuncture is a theatrical placebo. It is not supported by good evidence. Any apparent improvements are subjective rather than objective; they are small in magnitude and not clinically significant. Acupuncture is not entirely safe; it can cause serious complications and even deaths. Placebos, by definition, may “please” the patient, but it is unethical to prescribe them. And a placebo treatment that has no objective benefits and risks killing patients or putting them in the hospital has a particularly unacceptable risk/benefit ratio. There is no scientific justification for using acupuncture in clinical practice.