SBM regular Jann Bellamy frequently writes about what she refers to as “legislative alchemy“; that is, attempts by advocates of unscientific, pseudoscientific systems of medicine like traditional Chinese medicine or naturopathy to slap a patina of legitimacy on their quackery through state licensure of practitioners. There is another form of legislative alchemy, however, that doesn’t involve licensing quacks. There are two keys to the perception of legitimacy of a medical specialty among the public, and certainly one is licensure by the state. However, a second key is reimbursement for services by third party payers, particularly government payers like Medicaid and Medicare. Although I had been vaguely aware of such efforts before, to my knowledge they have been scattered and in general relatively unsuccessful, in contrast to efforts to .
I learned recently that Medicaid is the most recent target, with acupuncture the desired treatment, as an article in STAT News reported:
The quickest way to erase pain is to give patients an opioid. But a rise in prescriptions has fueled a national epidemic of fatal overdoses, with a large share of the deaths occurring in low-income communities.
Under intense pressure to combat the problem, states across the country are expanding their Medicaid programs to cover alternative treatments such as acupuncture, massage, and yoga. The effort could increase non-opioid options for low-income patients suffering from pain. But it also opens states to criticism from skeptics who say taxpayers are being forced to fund unproven treatments based on political expediency instead of sound science.
Ohio’s Medicaid department took the most dramatic step this month by extending coverage of acupuncture treatments delivered by non-medical providers for patients with low-back pain and migraines, a step likely to allow much greater access and attract new practitioners to the field.
Because I trained in Cleveland and still have connections there, I had taken note of the Cleveland.com article referenced in the STAT story, which provides more detail:
Starting January 1, more than 108,000 Ohioans on Medicaid who have diagnosed low back pain or migraines will be able to see an acupuncturist for pain management. The change in policy is part of an effort to reduce the number of unnecessary opioid prescriptions and overdose deaths in the state that arise from treating chronic pain with addictive drugs.
For the past year, Ohio has been one of six states in the country to cover acupuncture treatments for Medicaid patients, but only when offered by a doctor. Starting tomorrow, Medicaid reimbursement will be open to licensed non-physician acupuncturists who register as Medicaid providers.
The agency hopes that expanding access to the treatment, a centuries-old pain-relief technique that involves inserting hair-thin needles into the skin at specific points, will save money over time on addiction treatment and other costs related to opioid use.
Practitioners and their patients say it’s about time more people had access to the proven and safe, but expensive, non-drug therapy, and that more insurers should follow suit.
These sorts of decisions are the culmination of a strategy that is as old as alarm in public health circles about the rise of opioid addiction and the wave of overdose deaths sweeping the nation.
Co-opting the opioid crisis: A calculated strategy to sell quackery
It’s become increasingly clear to me that the opioid crisis has been adopted by advocates of “integrating” quackery into medicine as the most important new “foot in the door” or “wedge” to open the way to the legitimization and funding of pseudoscientific treatments like acupuncture. Basically, advocates of “integrative medicine” are taking advantage of the urgency of the current search for non-opioid and non-pharmacologic treatments for chronic pain to promote their placebo-based pseudoscience as the solution to the crisis. It’s become one of the main talking points used by advocates to open the door for the “integration” of mystical, prescientific, and pseudoscientific treatments like acupuncture into medicine. Indeed, whenever you hear the terms “non-drug therapy” or “nonpharmacologic management of pain” used by advocates with respect to the opioid crisis and chronic pain management, it’s code for placebo-based quackery. The quacks are not even subtle about it.
It’s a rationale that comes right from the top, from the most prominent proponents of “integrative medicine.” For instance, the National Center for Complementary and Integrative Health (NCCIH) featured the opioid crisis as a compelling reason for its existence in its latest five year strategic plan, which made the “nonpharmacologic management of pain” one of its top research priorities. Since then, NCCIH has been promoting such approaches, science-based or quackery like acupuncture, as its own, the better to seamlessly integrate pseudoscience with science. Elsewhere, the same sort of rationale is used to justify the introduction of quackery into the VA medical system. Even the FDA is considering encouraging knowledge about chiropractic and acupuncture as approaches for chronic pain.
It’s not just the NCCIH, the VA, and the FDA either. Journals, even prestigious medical journals, The BMJ and JAMA increasingly buy into the message that “nonpharmacologic treatment for chronic pain = ‘integrative medicine.'” Medical professional societies are jumping on the bandwagon as well. For instance, the American College of Physicians included acupuncture on its list of recommended strategies for low back pain. An entire professional organization, the Society for Integrative Oncology, is devoted to diluting the science of oncology with a mixture of lifestyle interventions that are in no way “alternative” or “integrative” plus pseudoscientific nonsense. Even NCI-designated comprehensive cancer centers like Memorial Sloan-Kettering Cancer Center are increasingly “integrating” quackery with oncology. And don’t even get me started on “naturopathic oncology,” which is becoming increasingly accepted and metastasizing outside of academia.
The strategy is starting to work, as STAT reports:
But Ohio is not alone. Eleven other states have implemented policies to encourage beneficiaries to use alternative therapies to help manage their pain and limit reliance on opioids, according to a 2016 survey by the National Academy for State Health Policy. In addition to acupuncture, covered services include massage, yoga, chiropractic manipulation, and various forms of physical and behavioral therapy, among others.
Two states, Maine and Vermont, are currently considering whether to expand coverage of acupuncture to treat pain after conducting studies to test its effectiveness for beneficiaries.
More on Maine and Vermont later. First, back to Ohio.
Meanwhile, back in Ohio…
So let’s take a closer look at what’s going on in Ohio by going back to the Cleveland.com article:
Dr. Maya Myslenski, a pediatrician who practices in the emergency department at MetroHealth Medical Center, has been offering acupuncture to her patients for a variety of ailments for more than two years. It helps patients with both acute and chronic pain, anxiety, and some stomach ailments, she said.
“A lot of our [Medicaid] patients can’t afford to go to private offices for treatments,” Myslenski said. “I’m beyond thrilled about treatments being covered for them.”
Noooo! During my residency at University Hospitals of Cleveland, I did part of my training at MetroHealth Medical Center, particularly for trauma. I moonlighted as a helicopter flight physician for Metro LifeFlight, which is based at MetroHealth Medical Center.
Unfortunately, this article is quite credulous about acupuncture, repeating the usual tropes used to justify it:
In Ohio, the move to cover acupuncture for chronic pain conditions began in earnest in January of 2016, when Gov. John Kasich’s Cabinet Opiate Action Team (GCOAT) released a guideline for the management of acute pain outside of emergency departments. The guideline said that non-drug therapies such as acupuncture (as well as physical and massage therapies, biofeedback and hypnotherapy) should be considered as first-line treatments for acute pain. The Governor’s team also encouraged Medicaid to further research and review acupuncture.
Then in January of 2017, the Joint Commission, the not-for-profit organization that certifies hospitals have met certain safety standards, changed its pain management standards to require that accredited hospitals provide nonpharmacological pain treatments.
Around the same time, the American College of Physicians issued new guidelines for the treatment of low back pain, which recommended that doctors treat patients with non-drug therapies first, including acupuncture.
One more time: The ACP guidelines were poorly conceived and based on weak science. I’ve also mentioned the Joint Commission’s recommendations before. While it’s not unreasonable to promote the use of nonpharmacological approaches to pain, those approaches must be science- and evidence-based. So far, advocates of unscientific approaches like acupuncture have been getting away with using the opioid crisis as a cover to advance their quackery and even get the government and insurance companies to pay for it. They’re not even subtle about it:
“It may take another year or so, but I do think it’s going to lead to a change in policy,” he said. “The opioid crisis has helped the establishment catch up a little to research on acupuncture. There’s been a big change in attitude in terms of openness to this sort of thing.”
The person making the above statement is Robert Davis, a Vermont acupuncturist who led the state’s pilot testing acupuncture for back pain. Yeah, that gives me a lot of confidence in the scientific validity of the pilot studies being done in various states. I note that his website basically relies on testimonials to claim that acupuncture “works”; well, that and “ample clinical experience, supported by some research data.”
I also can’t help but note that even the author of this story lazily cites a “meta-analysis” from the Australian Acupuncture and Chinese Medicine Association that was not published in any peer-reviewed journal as “evidence” for the efficacy of acupuncture, as he lays down quotes like:
West said the research on acupuncture has become much clearer in recent years, both on how well it works and how it can save money.
“There are some really big, recent studies that clearly show that acupuncture is not only comparable to Western medicine in how effective it is, but it’s safer and it’s cost-effective,” West said. “In chronic low back pain, you can save money over the long-term, give people just as good care and they’re not getting addicted to pain medication.”
It costs the insurer between 70 cents and $1 per month, per policy, to add acupuncture coverage, West said. “It just doesn’t make sense not to when we’re spending $1 billion a year in Ohio on addiction treatment.”
No, when you’re spending $1 billion a year on addiction treatment for Ohio residents, it doesn’t make sense to waste money on ineffective and pseudoscientific treatments. What’s next? Narconon? Also, no, there are not “really big, recent studies that clearly show that acupuncture is comparable to “Western” medicine, much less cost effective. In general, most studies of acupuncture tend to be relatively small, poorly controlled, and equivocal in results, while meta-analyses of acupuncture studies are generally the epitome of “garbage in, garbage out.” In general, the larger and better designed the acupuncture study, the smaller the effect, with the effect size being in essence zero in the very best studies. Moreover, it doesn’t matter where you place the needles or even if you place the needles in; the effect is the same, nonspecific. Acupuncture doesn’t work. It is theatrical placebo.
As for Jared West, who was quoted above, he’s an acupuncturist, of course. Not surprisingly, he offers acupuncture, moxibustion, and cupping quackery. He’s also president of the Ohio Association of Acupuncture and Oriental Medicine and is helping providers navigate the Medicaid registration process and has advised the state on reimbursement and other issues.
The STAT article notes several other states considering letting Medicaid recipients choose acupuncture and other alternative treatments, which brings us back to Vermont:
“Acupuncture is not going to solve the opioid crisis,” said Robert Davis, an acupuncturist who led Vermont’s Medicaid study. “But acupuncture is one tool that helps patients. It helps them get their feet back under them.” Vermont’s study found that, among about 150 pain patients, acupuncture improved patients’ rating of pain, fatigue, depression, and other measures — though the study didn’t include a control group, and so may have reflected a placebo effect.
I encourage you to read the study. It was not published in any peer-reviewed medical journal, just on the Vermont Legislature website. It is an utterly worthless study, a total waste of Vermont taxpayer money. Indeed, you can tell this study is utterly useless from its design as described in the abstract:
A pilot-level prospective pragmatic intervention trial design was chosen as the most appropriate approach for this project after a thorough analysis of the legislative goals, resources, and timeline provided by Act 173, along with a review of the existing scientific literature. Several acupuncture trialists considered to be subject-matter experts by their peers were consulted in order to confirm the soundness of this approach. Qualitative interviews were also utilized to understand the experience from the patients’ perspective. Pragmatic trials are designed to answer questions useful to clinicians and policy makers because they aim to maximize external validity and generalizability to a real-world setting. This pilot included a heterogeneous group of chronic pain patients that were treated by Vermont-licensed acupuncturists who provided treatment in their private clinics in line with their standard practice. This design was intended to reflect what would happen if acupuncture reimbursement were offered for local chronic pain patients by the local population of acupuncturists. As a Phase 1 uncontrolled pilot, this study was designed to provide qualitative and implementation data that may help policy-makers. The Department of Vermont Health Access (DVHA) decided this was the best research design available in the short timeframe. A thorough description of the rationale for this approach is described in the Progress Report to the Legislature and a journal article published on this topic.
Whenever you hear the words “pilot” and “pragmatic” in a description of a study design for an intervention designed to treat a subjective complaint like pain, you know it’s guaranteed to show a positive result, thanks to placebo effects. Acupuncturists love pragmatic studies for this very reason. It is true that pragmatic studies are designed to test interventions as used in the “real world,” but there is an assumption behind them, namely that the treatment being tested has already been shown to be efficacious in well-designed randomized controlled clinical trials. Indeed, for real interventions, frequently what is found in pragmatic trials is that the treatment doesn’t work as well in the “real world” as it did in clinical trials, usually because of the variability and lack of consistency that inevitably arise when treatments are released “into the wild.” In the case of treatments that don’t work better than placebo but do induce placebo effects, pragmatic trials almost always show more efficacy than well-designed randomized trials. Again, that’s the point. This trial is so useless that it’s hardly worth even citing its results. If you want an idea of how biased this study is, just look at some of the comments from patients included in Appendix A:
- “My acupuncture was life changing… I saw and felt and continue to feel a marked difference in my pain and mental clarity. I believe it saved my life.”
- “Acupuncture helped me to get my life back.”
- “I was very skeptical about this treatment being effective. As the weeks went by, I noticed different changes taking place in my body: my digestive system functioned much better, so my diet improved; I required less sleeping medication because my sleep was better; my pain level was much decreased; I had more genuine energy; and most especially, I had better mobility. The mobility change enabled me to walk more in fresh air and increased my good energy level. A circle of reinforcements that has made my life much better, more productive and happier. It has cut down my need for other medical interventions like physical therapy and medications for various ailments. People have noticed the outward improvement.”
- “I went to a regular doctor for over six years and my pain only became more intense and more frequent. This is the longest I’ve gone without pain or medication in well over a year.”
- “this is a very necessary way to treat pain. I am very allergic to many medications and during the study I was able to walk and do more without an allergic reaction.”
You get the idea.
STAT does note that the evidence base for acupuncture is pretty thin, citing Cochrane reviews on acupuncture as a treatment for various conditions. Cochrane, for instance, points out that the there is a short term small benefit for patients with chronic low back pain but “notes that most studies are of low quality”; that acupuncture can help arthritis patients, but that the benefits are “too small, and too susceptible to placebo, to be considered clinically relevant”; and that acupuncture can offer a small benefit for migraines. (Note: Acupuncture doesn’t work for migraine, as Steve Novella has explained.)
Despite how poor its own study is, Vermont is using it to guide policy:
As states weigh the evidence and opposing arguments, many are moving cautiously. In Vermont, the Medicaid department is still considering how to translate the findings of its study into recommendations to state lawmakers, who will ultimately decide whether to expand coverage.
Oregon has created a similar approach, according to the survey by the National Academy for State Health Policy. The state covers several treatment options for patients with low-back pain, including acupuncture, chiropractic care, physical and occupational therapy, and behavioral therapy. The state also recommends treatment plans that include yoga, massage, and exercise therapy, although applicability of those services is determined by organizations that coordinate care for Oregon’s Medicaid beneficiaries.
Mark Crislip has previously noted how woo-friendly Oregon is.
The future of Medicaid?
Given the seriousness of the opioid epidemic and the public health imperative to institute policies to bring it under control, it is not surprising that integrative medicine advocates saw an opening. I don’t believe that they are being cynical or disingenuous (at least not the vast majority of them). Rather, they really believe that their quackery really can function as nonpharmacologic treatments for chronic pain. In other words, the vast majority of them are true believers, not scammers. The problem is that they are incorrect.
Alternative medicine, in particular acupuncture, is not the answer—or even one among many answers—to the opioid crisis. Worse, government funding tends to be a zero sum game, particularly now, which means that any funds diverted to pay for acupuncture and other alternative medicine, be it to provide services to those with chronic pain or to do research on non-opioid and non-pharmacologic treatments for pain, are funds not available to pay for science-based treatment. Unfortunately, I predict that acupuncture advocates and advocates of other unscientific treatments will likely be as persistent as naturopaths in pursuing their state-by-state legislative goals. As much as I’m half tempted to welcome them to the bureaucratic pain that is accepting Medicaid reimbursement and the very low reimbursement rates with a hearty, “Be careful what you wish for, you just might get it,” we proponents of science-based medicine need to resist these incursions in each state where we become aware of them.