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

Neuropathic pain is difficult to treat. Luckily, we have acupuncture! Acupuncturists leave us in no doubt that their needles are the solution. But are they correct or perhaps victims of wishful thinking?

This review was aimed at determining the proportion of patients with neuropathic pain who achieve a clinically meaningful improvement in their pain with the use of different pharmacologic and nonpharmacologic treatments.

Randomized controlled trials were included that reported a responder analysis of adults with neuropathic pain-specifically diabetic neuropathy, postherpetic neuralgia, or trigeminal neuralgia-treated with any of the following 8 treatments: exercise, acupuncture, serotonin-norepinephrine reuptake inhibitors (SNRIs), tricyclic antidepressants (TCAs), topical rubefacients, opioids, anticonvulsant medications, and topical lidocaine.

A total of 67 randomized controlled trials were included. There was moderate certainty of evidence that anticonvulsant medications (risk ratio of 1.54; 95% CI 1.45 to 1.63; number needed to treat [NNT] of 7) and SNRIs (risk ratio of 1.45; 95% CI 1.33 to 1.59; NNT = 7) might provide a clinically meaningful benefit to patients with neuropathic pain. There was low certainty of evidence for a clinically meaningful benefit for rubefacients (ie, capsaicin; NNT = 7) and opioids (NNT = 8), and very low certainty of evidence for TCAs. Very low-quality evidence demonstrated that acupuncture was ineffective. All drug classes, except TCAs, had a greater likelihood of deriving a clinically meaningful benefit than having withdrawals due to adverse events (number needed to harm between 12 and 15). No trials met the inclusion criteria for exercise or lidocaine, nor were any trials identified for trigeminal neuralgia.

The authors concluded that there is moderate certainty of evidence that anticonvulsant medications and SNRIs provide a clinically meaningful reduction in pain in those with neuropathic pain, with lower certainty of evidence for rubefacients and opioids, and very low certainty of evidence for TCAs. Owing to low-quality evidence for many interventions, future high-quality trials that report responder analyses will be important to strengthen understanding of the relative benefits and harms of treatments in patients with neuropathic pain.

This review was published in a respected mainstream journal and conducted by a multidisciplinary team with the following titles and affiliations:

  • Associate Professor in the College of Pharmacy at the University of Manitoba in Winnipeg.
  • Pharmacist in Edmonton, Alta, and Clinical Evidence Expert for the College of Family Physicians of Canada.
  • Family physician and Assistant Professor at the University of Alberta.
  • Family physician and Associate Professor in the Department of Family Medicine at the University of Alberta.
  • Pharmacist, Clinical Evidence Expert Lead for the College of Family Physicians of Canada, and Associate Clinical Professor in the Department of Family Medicine at the University of Alberta.
  • Pharmacist in Edmonton and Clinical Evidence Expert for the College of Family Physicians of Canada.
  • Pharmacist and Clinical Evidence Expert at the College of Family Physicians of Canada.
  • Family physician, Director of Programs and Practice Support at the College of Family Physicians of Canada, and Adjunct Professor in the Department of Family Medicine at the University of Alberta.
  • Professor in the Faculty of Pharmaceutical Sciences at the University of British Columbia in Vancouver.
  • Pharmacist at the CIUSSS du Nord-de-l’lle-de-Montréal and Clinical Associate Professor in the Faculty of Pharmacy at the University of Montreal in Quebec.
  • Care of the elderly physician and Assistant Professor in the Department of Family Medicine at the University of Alberta.
  • Family physician and Professor in the Department of Family Medicine at the University of Alberta.
  • Assistant Professor in the Department of Family Medicine at Queen’s University in Kingston, Ont.
  • Research assistant at the University of Alberta.
  • Medical student at the University of Alberta.
  • Nurse in Edmonton and Clinical Evidence Expert for the College of Family Physicians of Canada.

As far as I can see, the review is of sound methodology, it minimizes bias, and its conclusions are therefore trustworthy. They suggest that acupuncture is not effective for neuropathic pain.

But how can this be? Do the authors not know about all the positive evidence on acupuncture? A quick search found positive recent reviews of acupuncture for all of the three indications in question:

  1. Diabetic neuropathy: Acupuncture alone and vitamin B combined with acupuncture are more effective in treating DPN compared to vitamin B.
  2. Herpes zoster: Acupuncture may be effective for patients with HZ.
  3. Trigeminal neuralgia: Acupuncture appears more effective than pharmacotherapy or surgery.

How can we explain this obvious contradiction?

Which result should we trust?

Do we believe pro-acupuncture researchers who published their papers in pro-acupuncture journals, or do we believe the findings of researchers who could not care less whether their work proves or disproves the effectiveness of acupuncture?

I think that these papers offer an exemplary opportunity for us to study how powerful the biases of researchers can be. They also remind us that, in the realm of so-called alternative medicine (SCAM), we should always be very cautious and not accept every conclusion that has been published in supposedly peer-reviewed medical journals.

24 Responses to Acupuncture for chronic neuropathic pain? No!

  • ‘…or do we believe the findings of researchers who could not care less whether their work proves or disproves the effectiveness of acupuncture?’

    What makes you think these people don’t have their own biases? There are certainly many within the conventional medicine who hold very negative views about CAM. It’s also common knowledge that pharmaceutical companies have been known to offer ‘incentives’ of various kinds to doctors/pharmacists. None of this may apply to this particular review of course, but who’s to say? Bias is not the reserve of us loonies.

    • cannot prove a negative
      benefit of the doubt
      large multidisciplinary team

      • cannot prove a negative: sure, but this applies to research conducted by ‘SCAM enthusiasts’ too…
        benefit of the doubt: given to this team but not others with affiliations you don’t care for…
        large multidisciplinary team: of doctors/pharmacists…

        • “cannot prove a negative: sure, but this applies to research conducted by ‘SCAM enthusiasts’ too”
          no, because in their case we have ‘proof positive’
          benefit of the doubt: given to this team but not others with affiliations you don’t care for…
          no, because in their case we have ‘proof positive’

    • It doesn’t matter whether it’s that research in particular.

      Every alternative ”medecine” proponent has failed to provide any clear-cut demonstrable efficacy for multiple of the effects they claim through the scrutiny of the scientific method, which is the singlemost self-correcting method we have to evaluate reality.

      It is also particularly bemusing than when confronted with this, many of them resort to shifting the goalpost, red herrings, ad hominems and all sort of logical fallacies because they can’t account that maybe, JUST maybe, if you can’t demonstrate your method does something under scrutiny, maybe it’s just not better than placebo or luck.

      Big pharma (wether you like it or not) is subjected to such scrutiny. Medical interventions and technology is held to such a standard. Why is it that esoteric methods cannot do the same (pick your preffered poison).

      Lastly, the fact that people are prone to being influenced or bribed does not mean that the method is flawed. Just that the people applying it can be influenced and tinker with the results. However, when properly applied, it is easy and possible to compare treaments and come with a reasonable conclusion to their effectiveness, over and over again. After years of being held to scrutiny, we’re finally the closest we’ve been to being rid of snake oil peddlers, yet some people just want to peddle their oil.

      P.S. : Big pharma also has their hands in the snake oil peddling business, just because some people want to throw their money away does not make the treatment effective.

      The same kind of thinking goes for religions as well.

    • @Tom Kennedy

      What makes you think these people don’t have their own biases?

      If they have, it doesn’t show in their research.

      There are certainly many within the conventional medicine who hold very negative views about CAM.

      You’d be surprised at how many conventional medicine workers are quite neutral or even positive about alternative treatments, with higher popularity among nurses etc., and more neutral positions among doctors and specialists.
      Most doctors I spoke didn’t have any strong opinions on the subject; they mostly ignored it, having more than enough work already treating patients and keeping abreast of developments in real medicine.
      AFAICT, the most negative views of alternative diagnostic and treatment practices are found among researchers and other academics who are not involved with providing healthcare on a daily basis..

      It’s also common knowledge that pharmaceutical companies have been known to offer ‘incentives’ of various kinds to doctors/pharmacists.

      Yes, incentives to prescribe their products – NOT incentives to condemn or counter alternative treatments(*). Also note that in many countries, pharmaceutical companies are prohibited by law from influencing prescription policies of doctors, or from awarding perks in general (including even presents as trivial as branded pens) to doctors.

      Bias is not the reserve of us loonies.

      Well, in a way it is. Alternative practitioners are far more prone to bias than real doctors, mostly because most alternative practitioners have no scientific education and have not been taught to be critical of what they see and think. Real doctors (OK, the good ones, not the arrogant demi-gods) know that they can and do get things wrong, and that mistakes can have very serious consequences – so they tend to rely more on what is defined as the standard of care and on advances in medical science than on their own experience and observations. This is not to say that real doctors don’t suffer from biased thinking, but they are more likely to entertain the idea that they may be wrong than alternative practitioners.

      The latter category almost exclusively base their career on fallacies and biases, with false causality as the most common one: “We treat patients, and we see them get better – so the treatment works!” This is understandable in a way, as they don’t have a solid body of scientific knowledge to rely on, and they most definitely don’t do research that leads to progress in any way. Almost all ‘research’ in the Alternative Universe is characterized by one-off observations of a tiny effect, without any theoretical background, without explanatory mechanisms, and without any use whatsoever – not even among alternative practitioners themselves. They simply keep doing things as they always have, each individual practitioner basing their diagnoses and treatments on their personal beliefs and insights(**).

      *: And I challenge you to provide even ONE example where a pharmaceutical company actually lobbied against alternative treatments or its providers. In fact, alternative treatments can be quite a cash cow for pharmaceutical companies – they make more money from making vitamins and supplements than from e.g. vaccines.

      **: There was this TV documentary here in the Netherlands some years ago, where half a dozen journalists with real health conditions (e.g. eczema, recurring headaches and so on) each consulted several alternative practitioners as well as real doctors. In all, some 30 alternative practitioners and at least 4 real doctors were consulted.
      The results were as expected: alternative practitioners got almost all diagnoses wrong (except eczema – but then they still came up with completely different ‘root causes’ of the ailment), and no two practitioners suggested the same ‘treatment’ for the same condition. Yes, of course acupuncturists always offered acupuncture – but hardly ever sticking the needles in the same locations. They didn’t even agree within an inch or so on where particular meridians were located.
      The real doctors fared much better, correctly diagnosing the conditions in the vast majority of cases, and proposing more or less the same treatments. Some of which involved pharmaceutical products, and some of which didn’t.

  • @Richard

    ‘Yes, incentives to prescribe their products – NOT incentives to condemn or counter alternative treatments’.

    I’m not suggesting that these people have been directly sponsored to show acupuncture in a negative light. But it’s quite possible they are subject to unconscious biases. It’s well known that pharmaceutical companies put a lot of money and effort into promoting their brands to medical students and doctors/pharmacists, and that this can lead to irrational prescribing practices. Why wouldn’t these efforts also influence decision making in the design and implementation of trials and reviews?

    But I also want to look a bit closer at the RCTs included in this review. There were 3 in total.

    Garrow:

    This was a pilot study, and therefore the number of subjects wasn’t great enough to show statistical significance despite ‘small improvements…seen in VAS/MYMOP/SPS and resting diastolic BP in the true acupuncture group. In contrast, there was little change in those receiving sham acupuncture’. On the basis of this, surely reasons to follow up at least?

    ‘Observed improvements in the active acupuncture group, but not in the sham group, suggest that acupuncture may have a role in the treatment of some of the unpleasant symptoms associated with DPN. The study included only 59 participants and therefore some of the results may be susceptible to type II errors — that is, the sample size was too small for the observed differences between groups to appear statistically significant.’

    The treatments given in this study, in common with the other two, were standardised, which is inconsistent with the reactive and personalised nature of real world clinical practice. I understand the concept that standardisation reduces potentially extraneous variables, but the end result is that ‘real’ acupuncture is not being evaluated at all.

    Lewith:

    This trial is nearly 40 years old. Likewise, there is a small sample of just 62 (30 in the active group). Only 17 of these subjects received body acupuncture and completed the protocol (maximum of 8 sessions). All subjects in the active group started with auricular acupuncture only. The results showed no significant improvements in sham v real groups.

    Shin:

    This trial had a larger group of subjects, and at least a more representative selection of acupuncture points in my opinion (but they were still standardised). There were significant improvements in treatment vs no treatment group, but no placebo control. Electro-stimulation was used on the points.

    Overall:

    These three trials investigated three completely different styles of (standardised) acupuncture (auricular acupuncture; body acupuncture via a stuck on tube rendering normal practice impossible; and electroacupuncture). Overall 9% more patients receiving one of these active interventions attained clinically meaningful responses compared to control, but this was not deemed statistically significant.

    To Prof. Ernst this review is trustworthy, and it ‘suggest that acupuncture is not effective for neuropathic pain’. Yet even the authors point out that this is ‘very low-quality evidence’, and therefore any conclusion is of very low certainty. I would go further and say that this review is next to useless and tells us virtually nothing about the potential of real-world acupuncture to help patients with neuropathic pain. I sincerely hope the superficial, one-sided conclusions drawn in this post don’t discourage patients or researchers from digging deeper.

    To come back to my original point, while Big Pharma may be subject to scientific scrutiny, it also has unfathomable resources to lobby, cajole, and force their agenda, as well as fund research. ‘Why is it that esoteric methods cannot do the same?’ – we simply don’t have the means. And when we do attempt to contribute to the evidence base, it is deemed untrustworthy/subject to a high risk of bias. Is it any surprise that most practitioners instead focus their efforts on trying to help their patients instead?

    • yes, it’s low quality.
      so, where is the high quality that shows acupuncture is effective?
      unless there is some, it must be viewed as not effective! got it?

      • No, I don’t get it. The evidence (even in this very thin selection, and even when using a poor imitation of acupuncture) shows better results for the active groups. So all that can be concluded is that (many) more studies are required to draw any meaningful conclusion. In the meantime hopefully open minded doctors will consider referring their suffering patients based on the relative safety of the intervention and the hints at favourable outcomes (as two of the three authors of the included trials concluded).

        • yes, of course!
          you and many others need to make a living despite the lack of sound evidence.

        • @Tom Kennedy

          … hopefully open minded doctors will consider referring their suffering patients based on the relative safety of the intervention and the hints at favourable outcomes.

          Safety is meaningless without proven efficacy.

  • How many commonly used pharmaceutical drugs really have proven efficacy?

    ‘ Doctors today commonly assert that they practice “scientific medicine,” and patients think that the medical treatments they receive are “scientifically proven.” However, this ideal is a dream, not reality, and a clever and profitable marketing ruse, not fact.’ (https://www.huffpost.com/entry/how-scientific-is-modern_b_543158)

    ‘Our preference for black or white over shades of grey is convenient but it can offer only a “false clarity”’ (https://bmcmedicine.biomedcentral.com/articles/10.1186/s12916-015-0494-1).

    Within the shades of grey there is an important role for acupuncture and herbal medicine.

    • an article by Dullman?
      the prime homeopathic quack to support acupuncture?
      are you serious?
      you seem to think: in conventional medicine not everything is pukka, therefore we acupuncturists are allowed to carry on doing nonsense.

    • @Tom Kennedy

      How many commonly used pharmaceutical drugs really have proven efficacy?

      This is the good old ‘Tu Quoque’ fallacy.
      – Even if all pharmaceutical products would have no proven efficacy, then that still does not mean that it’s OK to sell the public other ineffective treatments. All ineffective treatments should be abandoned, regardless of their nature.
      – All pharmaceutical products are required by law to have at least some evidence of efficacy – and most indeed have some proven beneficial effect in at least some patients(*). Also note that pharmaceutical products are no longer prescribed when they a) turn out not to work, or b) are superseded by better treatments or products.
      – There is no legal requirement of efficacy for alternative modalities – and even though properly conducted trials of these modalities almost always come up negative, as in ‘not effective beyond placebo’, they are never abandoned, no matter how obviously useless and they are.

      *: Yes, I know that pharmaceutical companies sometimes fudge the numbers in order to make their new, hugely expensive product look better, but this also does not mean that other providers of treatments should also lie to the public about their products and services as well. It means that those cheating companies should be severely punished. And they are.

  • I thought Ullman summed up the situation in conventional medicine nicely so I used his quote – that doesn’t mean I agree with or endorse everything he says. Again, shades of grey.

    As usual, you haven’t really addressed any of the genuine and reasonable points I’ve tried to make about your post and the science behind it. Instead you look for pithy ways to discredit and ridicule and play to your audience. No reasoned debate, only scientific fundamentalism.

    • your reasonable point: conventional medicine is far from perfect.
      solution: keep improving it
      non-solution: use dodgy therapies instead

      • There is a lot of evidence showing that acupuncture has real effects on pain, and therefore real effects on reducing suffering. To me that’s rather wonderful and not ‘dodgy’ at all. Conventional medicine is far from perfect, so until it is, why not keep exploring interventions which might help to improve what it has to offer.?

        • because there isn’t a lot of good evidence for neuropathic pain, the subject of my post

          • OK, but bearing in mind the evidence for pain in general, and the fact that two of the three trials included here showed positive results, your spin seems rather negative and not conducive to further progress:

            ‘Acupuncture for chronic neuropathic pain? No!’

          • my spin?
            read the conclusions of the review I discussed here.
            also: stop using fallacies instead of arguments.
            perhaps my best advice to you: go on a course of critical thinking.

          • @Tom Kennedy
            “There is a lot of evidence showing that acupuncture has real effects on pain, and therefore real effects on reducing suffering.”
            So does virtually any kind of personal attention, especially when combined with distraction techniques, up to and including having clowns roam paediatric wards in hospitals.

            Who knows, maybe you should trade your needles and qi charts for a whopping big red nose and a mop wig?

  • @Richard Or maybe Doctors should selectively trade their medications for needles and red noses?

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