MD, PhD, FMedSci, FRSB, FRCP, FRCPEd.

Today, the BMJ published our ‘head to head‘ article on the above question. Dr Mike Cummings argues the pro-part, while Prof Asbjorn Horbjardsson and I argue against the notion.

The pro arguments essentially are the well-rehearsed points acupuncture-fans like to advance:

  • Some guidelines do recommend acupuncture.
  • Sham acupuncture is not a valid comparator.
  • The largest meta-analysis shows a small effect.
  • Acupuncture is not implausible.
  • It improves quality of life.

Cummings concludes as follows: In summary, the pragmatic view sees acupuncture as a relatively safe and moderately effective intervention for a wide range of common chronic pain conditions. It has a plausible set of neurophysiological mechanisms supported by basic science.12 For those patients who choose it and who respond well, it considerably improves health related quality of life, and it has much lower long term risk for them than non-steroidal anti-inflammatory drugs. It may be especially useful for chronic musculoskeletal pain and osteoarthritis in elderly patients, who are at particularly high risk from adverse drug reactions.

Our arguments are also not new; essentially, we stress that:

  • The effects of acupuncture are too small to be clinically relevant.
  • They are probably not even caused by acupuncture, but the result of residual bias.
  • Pragmatic trials are of little value in defining efficacy.
  • Acupuncture is not free of risks.
  • Regular acupuncture treatments are expensive.
  • There is no generally accepted, plausible mechanism.

We concluded that after decades of research and hundreds of acupuncture pain trials, including thousands of patients, we still have no clear mechanism of action, insufficient evidence for clinically worthwhile benefit, and possible harms. Therefore, doctors should not recommend acupuncture for pain.

Neither Asbjorn nor I have any conflicts of interests to declare.

Dr Cummings, by contrast, states that he is the salaried medical director of the British Medical Acupuncture Society, which is a membership organisation and charity established to stimulate and promote the use and scientific understanding of acupuncture as part of the practice of medicine for the public benefit. He is an associate editor for Acupuncture in Medicine, published by BMJ. He has a modest private income from lecturing outside the UK, royalties from textbooks, and a partnership teaching veterinary surgeons in Western veterinary acupuncture. He has participated in a NICE guideline development group as an expert adviser discussing acupuncture. He has used Western medical acupuncture in clinical practice following a chance observation as a medical officer in the Royal Air Force in 1989.

My question to you is this: WHICH OF THE TWO POSITION IS THE MORE REASONABLE ONE?

Please, do let us know by posting a comment here, or directly at the BMJ article (better), or both (best).

29 Responses to Should we recommend acupuncture for pain relief? … WHAT DO YOU THINK?

  • I’ll trust you, Dr Ernst. on this one. The accupuncturists (is this a newly coined term?) have to show the positive effect their treatment has by trails just like any other drug or intervention. So far they preach no research.

  • Well done, Edzard (& Asbjorn)! I noticed that you are still at the Exeter university! Have they taken you back? Would be very clever of them.

  • Maybe it is only me but a massage, given by your partner, or a hot relaxing bath will probably work better for pain relief than acupuncture. Problem is, it’s not mystical enough and quacks can’t make money out of it.

    It might however be a good idea to compare these three ‘interventions’ – if it hasn’t been done already. I think acupuncture will fare badly compared to the other two.

  • In what way is acupuncture ‘not implausible’?

  • “It’s a safe alternative to drugs that is under-researched because it lacks commercial interest, writes Mike Cummings”

    This introduction is followed by a long list of references for research on the subject, including systematic reviews of multiple studies. I wonder if this subject is “under-researched” because of the results obtained so far.

    The lack of commercial interest is news to me. From the association website I could not find the number of members they have, only that they have a discounted fee for those who earn less than £38K p.a..

    • Nice call, VDG.

      The British Acupuncture Council website lists no fewer than 67 conditions for which there is published evidence about ‘how acupuncture can help’. All six of the conditions I looked at at random cited at least half a dozen research publications. The BAC claims to have more than 3,000 members.

      You already referred to The Acupuncture Society. In addition to this and the BAC there’s a British Medical Acupuncture Society and a British Acupuncture Accreditation Board. Seems to me there’s a pretty massive interest in having bodies with official-sounding names for acupuncturists. I guess these folks have a self-esteem problem. Can’t think why.

  • First a disclosure. I stick needles in people as a component of pain management. I am certainly biased.

    Second. Dr. Ernst. I think perhaps you are perhaps being a little uncharitable to Dr. Cummings. He actually did identify sources of bias. Certainly you, like all of us with strongly invested perspectives, have biases and cognitive heuristics that feed these. Perhaps I am mistaken, but you don’t appear to acknowledge this by your comments.

    Third – a reasonable but evolving mechanism: If you follow the physio literature there is much discussion about chronic pain as involving centrally mediated pathways. A nice summary: https://www.ncbi.nlm.nih.gov/pubmed/26051220 Needles, as an active neurological stimulus, presumably affect these pathways. You might call this a physiologically active placebo but why harp on this if it reduces pain.

    Forth, I think that much of the medium to long term acupuncture affects may reflect regression to the mean or other non-specific effects. But I also believe that there are short term effects that have benefit in facilitating what is essentially most important – exercise (rehab) and activity (as a component of the plan). If this reduces patient avoidance patterns and gets people moving, I’m all for it.

    Best,

    Hal Huff

    • 1) thanks for your honesty
      2) I often disclosed my biases, most recently here: http://edzardernst.com/2018/03/my-ideological-biases/
      if you know more, please tell us.
      3) yes, many (more or less nebulous) mechanisms have been suggested but, as we stated: “we still have no clear mechanism of action”
      4) interesting beliefs! but I prefer data/evidence.

    • A reasonable mechanism? Handwaving “discussion” would be more correct. Sticking needles into the body will have physiological effects. If it’s no better than placebo then whatever effects the needles may have they cannot be reducing pain – directly or otherwise. A placebo, of itself, is necessarily powerless. Otherwise it’s a useless comparator for non-specific effects. Suggestion is very powerful.

      If sham is not a valid comparator then the null hypothesis stands unrefuted and unrefutable. We move beyond the realm of science. The question of ethics arises. We then have an exercise in faith healing. Faith in needles, faith in person in white coat. Should shamanism be part of a doctor’s vocation these days?

      Why would acupuncture necessarily facilitate exercise? It might deflect some people away from it.

      • Leigh Jackson. Nice rant!

      • There are better, safer and more honest ways of entertaining pain sufferers than tell them tall stories about oriental magic and imaginary physiological effects and stick them with needles in non-existent, incoherently defined points.

        Even better is to educate and coach a chronic pain sufferer and helping him live with pain. Careful, monitored, systematic testing of medications can sometimes lead to life changing improvements.

        • For the most part I agree with you statement. Managing suffering is most important. No need to discuss TCM theory and channels except as perhaps an interesting historical context. It is important to be honest and to discuss uncertainties/limitations. And even sometimes medications can be helpful (but rarely in this context life changing)

          But, the points are not always incoherently selected, they are often where the pain is. How can you state that there is no physiological effect – this doesn’t make sense, and fact is, there is no slam-dunk treatment for chronic pain

      • It might deflect some people away from it.

        It definitely has the potential to do that. Who would exercise when they have the preconception of an easy solution for pain management in needling (in exchange for money)? Even as a placebo, needling manifests itself as a deviation from actual interventions and this is ethically unacceptable.

  • Re 2. since you invited FU) Your ideological biases all seem commendable. But in your post you seem to be narrowing the problem of bias down to specifically bias against people or groups. You appear to be relating these biases as commendable attributes. On the other side of this of course is that your ideology, self-identity, and perhaps your public persona influence your capacity to see things as they really are. You are a ‘fool’ “fooling” [ref] yourself. That’s the whole justification for scientific thinking. Your post appears to lack the humility that this entails. Sorry I don’t mean to hijack and redirect this post. My point is to clarify my comments, not to insult you (perhaps I’m taking your post too literally).

    Will follow-up on the other points when I get a chance – interesting discussion

    • meanwhile: do you have any evidence for any bias that I may be the victim of?

      • Evidence? well you are human. I suspect that you are inflicted to some extent by all the common biases; as am I.

      • @Hal humility is not something I associate readily with this blog.

        @Edzard presumably you receive income from your books and lectures espousing a sceptical approach to CAM? To give ground to ‘acupuncture fans’ would undermine this income stream, wouldn’t it? Isn’t that a conflict of interest in itself?

        • there is no income stream!
          lectures: normally nor even the travel costs are fully covered.
          books: forget it; peanuts and on balance clearly a deficit

          • books: forget it; peanuts and on balance clearly a deficit

            Indeed. Unless one is extremely lucky – which does happen, in the way there are also lottery winners – one derives no net income from books, on the contrary. That is also my experience. In fact, after seven books, I pulled out of it altogether.

          • i never wrote anything in my live with a view of increasing my bank balance.

    • @Hal

      How highly do you rate homeopathy?

  • 3) “we still have no clear mechanism of action” Granted yes, but this does not imply no benefit. Many drugs are used off label for conditions without known clear mechanisms. Even on label: there is no clear mechanism for Lithium in bipolar. Also, we have no clear mechanism on how rehab exercise reduces pain (in the short and long term).

    What we do know: Inserting a needle beyond the dermis is a stimulus, sometimes painful, and this is a definite physiological effect. You could call it an active placebo, but either way in some people, perhaps especially in those with the right genetic profile (those more susceptible to placebo effects) the stimulus is associated reduced pain. In this scenario sham and ‘acupuncture’ effects are not different (the study differences may be due to bias).

    4) interesting beliefs! but I prefer data/evidence.
    What do you consider as sufficient data/evidence?

      • I will gladly review your evidence post and come back – we’re off for the Canadian March-break vacation so could be a week or so. For some context though, I have given quite of bit of thought to the topic (I have some training in this; though perhaps totally lost on me:). I think that my general framework in this regard aligns with Sackett’s description of EBM: Evidence based medicine: what it is and what it isn’t http://www.bmj.com/content/312/7023/71

        Medicine is particularly messy and relatively few clinical decisions can actually be accomplished on the basis of hard evidence – certainly it is a challenge to distill practice oughts down to black and white statements. Just look at any guideline and count the high number of recommendations made by consensus opinion. Towards obtaining informed consent I prefer to present the patient with an honest discussion that includes potential benefits, trade offs, and frank uncertainties.

  • Please note, the BMJ article asked , “Should doctors recommend acupuncture for pain?”

    Setting aside the remarkably poor English – surely no one would use acupuncture to cause pain? What was meant is ‘pain relief’ or ‘to treat pain’, BMJ editor please note – the question is whether doctors should recommend the use of acupuncture.

    Doctors are ethically bound to use treatments which benefit patients, taking into account any risks. Ethically, doctors can carry out research into innovative treatments, but the answer to the question posed about whether doctors should recommend acupuncture must be: ‘No, because although consulting with an acupuncturist can have an effect (as Dr Cummings himself states: “For those patients who choose it and who respond well, it considerably improves health related quality of life…”), we know how such benefit is achieved – acupuncture is a theatrical placebo. If it works to relieve pain (the question posed), it should work on a wide variety of patients, not just “those who choose it” and who are already part seduced.

    As for doctors recommending acupuncture, it could be said there is nothing unethical about using such a placebo, providing the patient is told that is what it is. But how many patients agreeing to submit to acupuncture do give fully informed consent? And surely, doctors who fail to obtain fully informed consent are acting unethically and might be regarded as quacks.

    Acupuncture is one of an array of practices used by camists, most of whom are not doctors registered with the GMC. Dr Cummings has failed to address whether or not doctors should engage in such practices, but rather has avoided that question and sought to answer a different question -justifying acupuncture on the grounds it has a beneficial effect in moderating pain. I do not doubt that the care Dr Cummings gives his patients helps them deal with their pain and makes them feel better. But that attests to his charisma and skills at TLC. The pins and needles have no reproducible worthwhile effect. His reply to the question as posed applies the logical fallacy of a red herring.

    Ad hominem is to be avoided, but Dr Cummings has built his career since leaving the RAF on the premise that needling patients has an effect greater than simply caring for them. Perhaps the needles act as a hypnotist might use a swinging pendulum – to induce the response expectances – but the fact remains there is no proven benefit from needling patients.

    As for research – has anyone carried out ‘genuine’ acupuncture on a group of anaesthetised patients (for any minor surgery procedure), and compared the outcome to a group of patients told after recovery that they had been needled, when they had not been? Thought not. But if the outcome was identical, the value of the needling process would be disproved – and acupuncturists could stop subscribing to courses, conferences, books and journals describing the meridians (and labeling them, ‘T37; F65…’) – and to providing careers for protagonists. The money saved could be spent on caring.
    (Such research would be ethical if both groups of patients were told the nature of the experiment and consented to take part.)

    Acupuncture takes its name from the Latin for ‘a needle’ – acus . I would prefer we use the Greek – belone . ‘Belonetherapy’ seems more apt. Doctors should not be involved.

  • Here is an interesting article in this context:
    https://www.ncbi.nlm.nih.gov/pubmed/23707680

    I read the conclusions of this article to indicate that in order to obtain significant benefit from acupuncture, you need to optimise the deception involved. The abstract concludes as follows:

    This is the first study to show that under optimized blinding conditions, nonspecific factors such as patients’ perception of and expectations toward treatment are central to the efficacy of acupuncture analgesia and that these factors may contribute to self-reinforcing effects in acupuncture treatment. To obtain an effect of acupuncture in clinical practice, it may therefore be important to incorporate and optimize these factors.

    The conclusion in the full text article is as follows:

    The fact that a treatment effect can be optimized by focusing on
    patients’ overall perception of the treatment and expectations toward
    the treatment is well known from the pharmacological literature
    [1,4]. Nevertheless, one important difference between
    pharmacological and acupuncture treatment may be that needle
    penetration produces small or no specific effects [15,42]. Hence,
    if acupuncture needling is implemented in a traditional biomedical
    treatment setting, as it has been done to a higher extent in present
    years, awareness of patients’ perception of the treatment and their
    expectations toward the treatment may be pivotal in order to obtain
    an effect of the treatment.

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