In the third and final installment in our annual review of Legislative Alchemy – the deliberate incorporation of pseudoscience into health care via legislation – we take a look at 2017-2018 bills aiming to license and expand the scope of practice of acupuncturists and Traditional Chinese Medicine (TCM) practitioners, as well as eliminate their competition. (We previously covered chiropractic and naturopathic Legislative Alchemy.)
Acupuncture occupies an exalted place in the pantheon of CAM practices. Though it is no more scientifically plausible or evidence-based than a number of other CAM modalities generally rejected by “conventional” medicine (e.g., chiropractic, naturopathy, homeopathy), acupuncture has been embraced by the medical community.
The University of California San Diego School of Medicine’s Center for Integrative Medicine, for example, promotes acupuncture for a long list of diseases and conditions. The Center claims that “case-controlled clinical studies have shown that acupuncture has been an effective treatment” for, among others, leukopenia (low white blood cell count), turning a breech fetus, hypertension, and allergic rhinitis.
In the first place, case-control studies cannot determine the efficacy of a treatment. And, in fact, there is no reliable evidence (also here) that acupuncture is effective for any of these. The list specifically ignores a Cochrane Review conclusion that there is “no evidence that acupuncture is useful in the management of long-lasting hypertension.”
Disturbingly, the Center goes on to list several dozen more diseases and conditions for which it claims acupuncture has “limited but probable evidence” (that is, even less evidence) to support its therapeutic use, including bronchial asthma, cholecystitis (gallbladder inflammation), diabetes, hyperlipaemia, and schizophrenia.
The whole webpage is, in my view, irresponsible and potentially dangerous, yet is a useful demonstration of the credulous acceptance of acupuncture by the medical community.
Even putting aside the absurdity of promoting acupuncture to patients for all manner of ills, what most medical doctors likely don’t realize is that many acupuncturists have an extremely broad scope of practice, or would like to, if the push for initial licensing or practice expansion to include diagnosis and treatment far beyond sticking needles in “acupuncture points” is any indication. Thus, thanks to state legislators, a physician referring a patient to an acupuncturist will, perhaps unknowingly, expose the patient to the entire panoply of pseudoscience encompassed by a particular state’s acupuncture practice act.
Acupuncture “primary care”
Acupuncturists are licensed or otherwise regulated health care professionals in 47 states. A few states, like Michigan, limit the practice to needle acupuncture, although Michigan does not limit the diseases or conditions acupuncturists can treat. Other states give acupuncturists the authority to practice Traditional Chinese Medicine, with its plethora of pseudoscientific diagnoses and treatments (not to mention its threat to endangered species) or otherwise grant broad scopes of practice, including, in some cases, describing acupuncture as “primary care.” A few examples [boldface added in quotes]:
Nevada’s practice act defines “Oriental medicine” as
that system of the healing art which places the chief emphasis on the flow and balance of energy in the body mechanism as being the most important single factor in maintaining the well-being of the organism in health and disease.
“Acupuncture” is defined as
the insertion of needles into the human body by piercing the skin of the body to control and regulate the flow and balance of energy to cure, relieve, or palliate: (a) Any ailment or disease of the mind or body; or (b) Any wound, bodily injury or deformity.
Even though most herbal remedies are unproven and too many contain contaminants and substitutions, “herbal medicine” is defined as:
Suggesting, recommending, prescribing or directing the use of herbs for the cure, relief or palliation of any ailment or disease of the mind or body, or for the cure or relief of any wound, bodily injury or deformity.
My state, Florida, defines “acupuncture” as
a form of primary health care, based on traditional Chinese medical concepts and modern oriental medical techniques, that employs acupuncture diagnosis and treatment, as well as adjunctive therapies and diagnostic techniques, for the promotion, maintenance, and restoration of health and the prevention of disease.
The Florida Board of Acupuncture has expansively interpreted “adjunctive therapies and diagnostic techniques” to include reflexology, laser biostimulation, Kirlian photography, thermography, nutritional counseling, and recommendation of homeopathic remedies.
And in Arkansas,
Acupuncture’ means the insertion, manipulation, and removal of needles from the body and the use of other modalities and procedures at specific locations on the body for the prevention, cure, or correction of a malady, illness, injury, pain, or other condition or disorder by controlling and regulating the flow and balance of energy and function of the patient to restore and maintain health.
In Arkansas’s practice act “related techniques” include magnets, cold laser, and something called “ion pumping cord.” The Arkansas State Board of Acupuncture has enacted rules which take the scope of acupuncture practice even further to include ordering radiological, laboratory, or other diagnostic tests, Oriental medicine injection therapy, biofeedback, and prescription or administration of homeopathic medicine, enzymes, and glandulars. The rules also permit:
The stimulation of points or areas of the body using needles, heat, cold, light, lasers, sound, vibration, magnetism, electricity, bleeding, suction, pressure, Gua Sha, or other devices or means.
Yes, you read that right: Bleeding patients is perfectly legal in Arkansas.
2017-2018 Bills: licensing, practice expansion, turf wars
Despite their stunning successes in incorporating nonsense into law in most states, it looks like acupuncturists will suffer the same fate as naturopaths this year, with a complete shutout. And, as was the case with its naturopathic licensing bill, Michigan turned out to be a real nail biter.
Michigan, as mentioned, currently allows acupuncturists to register with the state and limits their practice to needle acupuncture. Senate Bill 683 would have allowed acupuncturists to become licensed and vastly expand their scope of practice to include laser acupuncture, electroacupuncture and dry needling as well as “dermal friction” (gua sha), cupping, prescribing herbal remedies, and homeopathy (which has nothing to do with TCM). Acupuncturists would be able to diagnose and treat any disease or condition in patients of any age using “traditional and contemporary East Asian medical theory,” which is undefined.
The bill would also allow the practice of auricular acupuncture for substance abuse treatment, under the supervision of an acupuncturist or physician, by anyone with a certification from the National Acupuncture Detoxification Association (NADA). NADA auricular acupuncture is based on a highly implausible mechanism of action and has never been proven effective for substance abuse. NADA’s promotion of auricular acupuncture is based on an unpublished and cherry-picked review of the evidence.
SB 683 passed in the Senate, successfully navigated the House committee system, then made it to a second reading before the full House. Thankfully, the clock ran out before the bill came up for a final vote.
Oklahoma is one of the three states that does not license or otherwise officially regulate acupuncturists. Three different licensing bills were introduced in the state Senate. Two bills (Senate Bills 1119 and 1501) contained similar provisions, permitting needle acupuncture for “promoting, maintaining and restoring health” even though acupuncture has not been proven to do any of these things, including alleviation of pain. They also permitted the practice of NADA auricular acupuncture for treating mental and emotional health, post and acute trauma, substance abuse, and chemical dependency. An acupuncture board would regulate acupuncturists, giving the fox the keys to the henhouse.
Senate Bill 1523 went even further, describing acupuncture as “primary health care” and allowing acupuncturists to diagnose, using fanciful methods like tongue and pulse diagnosis. Acupuncturists could, in addition to needle acupuncture, employ moxibustion, herbal therapies, and “other adjunctive properties”, and practice Oriental medicine. Under SB 1523, regulation would be under the state osteopathic board in consultation with an acupuncture committee.
Despite the full-court press of having three licensing bills introduced in one session, all failed.
In West Virginia, House Bill 4465 created NADA-trained “auricular acupuncture detoxification specialists” and would have allowed these “specialists” to perform “auricular acudetox” for the treatment of substance abuse, alcoholism, chemical dependency, detoxification, behavioral therapy, and trauma recovery. The bill actually passed in the House and Senate. The session ended before House could concur in a Senate amendment, dooming the bill.
In Minnesota, proposed legislation (Senate Bill 1958; House Bill 2389) would have the state spend $375,000 of taxpayer funds to study acupuncture for pain relief and the potential of acupuncture treatments to reduce opioid prescriptions. Here’s how the “study” would be conducted:
The study shall include collection of data from at least 200 cases where an individual receiving acupuncture treatment for pain relief had more than six but not more than 30 acupuncture treatments within a six-month period. Data shall be collected from at least ten treatment sites and ten referral sites, including both rural and urban sites. . . . The report shall analyze the collected data . . . from the referral practitioner, the treatment practitioner, and the individual participant.
In other words, a $375,000 unrandomized, uncontrolled, and unblinded collection of anecdotes, which would prove nothing. Fortunately, the state treasury won’t have to shell out the money because the bills failed.
There is a turf war going on between acupuncturists and physical therapists over the practice of “dry needling.” Acupuncturists claim that dry needling is the practice of acupuncture and sought to enshrine their view in Massachusetts law (House Bill 3247; Senate Bill 1182) by defining the insertion of filiform needles as acupuncture, thereby granting themselves a monopoly on the practice. Physical therapists disagree, pointing out that
The objectives and philosophy behind the use of dry needling by physical therapists is not based on ancient theories or tenets of traditional Chinese medicine. The performance of modern dry needling by physical therapists is based on western neuroanatomy and modern scientific study of the musculoskeletal and nervous systems.
The PTs won this particular battle; both bills died in committee.
The only legislative victories for acupuncturists were minor and did not involve initial licensing or practice expansion. Louisiana eliminated a requirement that acupuncturists have a relationship with a physician to provide for referrals and follow-up care. California extended the Acupuncture Board and its authority to regulate acupuncturists to 2023.
Public health, safety and welfare? Where?
The majority of state legislatures convene this month for a new session and the rest will soon follow. Acupuncturists, chiropractors, and naturopaths will be waiting at the statehouse doors with freshly-drafted bills granting them licensure and practice expansion. To my knowledge, other than delicensing naturopaths in a handful of states or making the practice illegal, no legislation has ever been introduced protecting the public from the useless and sometimes dangerous diagnoses and treatments CAM practitioners foist on patients. This is despite the fact that the states’ authority to regulate health care practitioners is constitutionally grounded in the police power, that is, the authority to protect the public’s health, welfare and safety. They are doing just the opposite. As Steve Novella pointed out just yesterday, it is high time politicians put patients ahead of these profiteers of pseudoscience.