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A recent segment on NPR is an excellent representation of some of the mischief that promotion of unscientific medical treatments can create. The title is a good summary of the problem: “To Curb Pain Without Opioids, Oregon Looks To Alternative Treatments.

The entire segment is premised around a false dichotomy, between excess use of opioids and unproven alternative treatments. It is clear that the reporters didn’t even speak to a pain specialist who relies upon science-based treatments, or if they did the specialist was completely ignored because a SBM approach did not fit into the narrative of the report.

Non-opioid options for pain control

The problem addressed by the segment is real – the current technology of pain control is limited. I don’t want to sell pain management short, we have an array of powerful and effective treatments. There are limitations, however, and many patients are inadequately treated.

Acute pain from trauma, surgery, or illness is usually not a problem. We can give powerful drugs to stop pain over the short term. The bigger challenge is chronic pain. There are also two types of pain, neuropathic and nociceptive. Neuropathic pain arises from the nervous system itself, a nerve misfiring, for example, and producing pain signals in the absence of any tissue damage. Nociceptive pain involves pain arising from outside the nervous system due to chronic tissue pathology, such as arthritis.

Neuropathic pain does not respond well to pain medication. Instead it is treated with neuropathic pain prophylaxis, which are drugs that essentially calm down the overactive nerve or neurons through a variety of mechanisms. These drugs work, but not always. Some neuropathic pain syndromes can be challenging to control.

Nociceptive pain responds to pain killers, which are called analgesics. However, nociceptive pain also has an underlying tissue cause, by definition, and this can be addressed also. If the source of pain is the muscles, then massage, physical therapy, moist heat, and muscle relaxants may help. If there is inflammation involved then anti-inflammatories are appropriate. If the joints, ligaments, and tendons are involved then mobilization, bracing, exercises, and other interventions may help.

Many patients, however, have chronic pain that is challenging to control. There are limited options for outpatient chronic treatments. NSAIDS (non-steroidal anti-inflammatory drugs, like aspirin) are a mainstay of treatment, but can cause stomach upset, and in severe cases even lead to ulcers. They also cause stress on the kidneys. Some patients may not be able to take NSAIDS for a variety of reasons. There is acetaminophen, which does not affect the stomach or kidneys, but can affect the liver. Without NSAIDS options quickly become limited.

There are migraine-specific medications for migraines (called triptans) but they don’t work for other pain syndromes. There are a variety of patches and creams, such as a lidocaine patch, that can be helpful for localized pain. After that we are essentially down to centrally acting drugs, such as opioids and the non-narcotic tramadol.

Opioids and pain

Opioids are very effective at pain relief. They not only reduce the pain, they affect the brain so that pain does not hurt, meaning they suppress the negative emotional response to pain.

The core problem with opioids is that they are both addictive and induce tolerance. Tolerance means that over time the medication is less effective, you need a higher dose to get the same effect. Even worse, there is evidence that chronic opioid use makes patients more sensitive to pain at baseline. Addiction means that chronic use results in drug seeking behavior and negative symptoms from withdrawal – the addiction is both psychological and emotional.

The dilemma for practitioners is that opioids work (at least in the short term) and no one wants to see their patients in pain when we have effective treatment. Patients suffering from chronic pain can get quite desperate and demanding. Further, once they experience the effect of opioids, the freedom from the negative emotional response to pain, they may become effectively spoiled for any other pain control strategy.

The false choice

This is where the poor reporting from NPR comes in. They report:

David Eisen, executive director of the Quest Center, is Keene’s “Dr. Dave.” He is board-certified in traditional Chinese medicine and acupuncture, and he says doctors need to stop thinking of opioids as a first-line defense against pain.

“There should be an array of things for people to choose from,” Eisen says, “whether it be chiropractic care, or naturopathic care, or acupuncture, nutrition, massage. Try those things — and if they don’t work, you use opioids as a last resort.”

Dr. Dave is presenting a false dichotomy, between using opioids as a first choice or using alternative treatments. There is, of course, a third science-based approach (completely ignored in this report). In my opinion, a good approach to chronic pain does not use opioids as a first line treatment, but as a last resort and in a limited and carefully monitored way.

Prior to resorting to opioids for chronic pain (again, distinguishing this from acute severe pain and also terminal pain), a practitioner should identify and address any underlying cause of the pain. This includes treating any neuropathic component and addressing any muscular, joint, and soft-tissue sources of pain. Physical therapy and all of its associated methods are often effective and science-based approaches to tissue pain. Lifestyle factors, such as weight, exercise, and exacerbating factors, also need to be addressed.

Within the marketing fiction of the alternative medicine world, however, mainstream medicine is all drugs and surgery. They contrast themselves to a fictional straw man version of science-based medicine, which is exactly what the NPR report did, giving listeners a distorted view of the modern practice of pain management. The purpose of this, of course, is to divert patients to ineffective but expensive “alternative” treatments.

The only hint of skepticism was in the final paragraph:

Oregon has not found overwhelming evidence that acupuncture, yoga or spinal manipulation work better than other options. But, as Taray points out, these alternatives don’t involve drugs.

Neither does physical therapy, exercise, and lifestyle changes – which are not “alternative” despite often being lumped in with pseudoscientific practices in order to lend legitimacy to the false category of “alternative” medicine.

Acupuncture for pain

One of the modalities that is perhaps most prominent in terms of alternative pain management is acupuncture. The degree to which this pseudoscientific treatment has penetrated mainstream medicine is disturbing, and its promotion is based entirely on misdirection.

Acupuncture involves sticking thin needles into acupuncture points. Various possible mechanisms are proposed, none proven. The traditional explanation is that the needles alter the flow of “chi” or life energy. This is pure pre-scientific superstition. Modern defenders have tried to dress up acupuncture in more scientific language by invoking more plausible mechanisms, but there is nothing that is specific to acupuncture or that necessarily results in practical pain control.

After thousands of studies there are a few things we can say with a very high degree of scientific confidence – acupuncture points do not exist, and as a result it does not matter where you stick the needles. In fact it also does not matter if you actually stick needles through the skin or just poke the skin randomly with sham needles or toothpicks.

In short – acupuncture does not work. It is nothing more than an elaborate placebo with clinically insignificant results. It is a medical dead end that should be entirely abandoned. If there turns out to be some sliver of a real effect from tissue manipulation or electrical stimulation, these things are not acupuncture in any case. Acupuncture adds nothing to our understanding of pain or how to control it.

Acupuncture for low back pain, the treatment specifically mentioned in the NPR report, demonstrates all the problems with the acupuncture literature. The best controlled studies, such as the 2009 toothpicks study, show no difference between “real” acupuncture, sham acupuncture using the wrong points, and placebo acupuncture that doesn’t even use needles.

Systematic reviews are often wishy washy, trying to put a positive spin on the data, but they often give the game away. The latest systematic review concludes:

Systematic reviews of variable quality showed that acupuncture, either used in isolation or as an adjunct to conventional therapy, provides short-term improvements in pain and function for chronic LBP. More efforts are needed to improve both internal and external validity of systematic reviews and RCTs in this area.

In other words, there are good studies, and not-so-good studies, with inconsistent results. Results only seem to be present when there is an unblinded comparison, or when blinding is uncertain, and they tend to be short-lived and of dubious clinical significance. They also often mix in “electroacupuncture,” muddying the waters with electrical stimulation, which has its own effect. This pattern of results is most consistent with background noise, not a real clinical effect. If it is this difficult to tease out a tiny clinical effect, perhaps it is not real.

Conclusion: Marketing and branding, not science

The NPR report demonstrated one of the marketing strategies for dubious but highly profitable medical treatments – brand them as “alternative” and then compare them to a straw man of bad medical practice.

There are many opportunities for this approach because medicine is complex and imperfect. We face many challenges, our scientific information is incomplete, and there are many conditions for which we lack effective treatments or where hard trade-offs need to be considered.

Instead of taking a rigorous scientific approach to slowly improve our knowledge and the practice of medicine, the “alternative medicine” world offers magic solutions and false promises. In addition they poison the well of mainstream medicine by spreading misleading negative stereotypes about their competition.

 

 

Posted by Steven Novella

Founder and currently Executive Editor of Science-Based Medicine Steven Novella, MD is an academic clinical neurologist at the Yale University School of Medicine. He is also the president and co-founder of the New England Skeptical Society, the host and producer of the popular weekly science podcast, The Skeptics’ Guide to the Universe, and the author of the NeuroLogicaBlog, a daily blog that covers news and issues in neuroscience, but also general science, scientific skepticism, philosophy of science, critical thinking, and the intersection of science with the media and society. Dr. Novella also contributes every Sunday to The Rogues Gallery, the official blog of the SGU.