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Acupuncture = Placebo. AGAIN.

30 March 2011

I wrote this just a few days ago, but it looks like I’ve missed the boat by not publishing immediately. The misleading headlines are already appearing:

Mark my words: that is NOT what the data show. A more accurate headline would read:

  • Real acupuncture no more effective than placebo treatment.

But before you get all up in arms about the sorry state of science journalism, let me assure you that it’s not really the reporters’ or editors’ fault. At least, not completely. In this case, the press release itself uses misleading language, with a headline claiming that “Acupuncture is equally effective with simulated needles.” So the average journalist should be forgiven for thinking that this study supports the validity of acupuncture—which it most certainly does not.

So what’s the real story?

Acupuncture often looks like science-based medicine. It's not. (NYCTCM Acupuncture Clinic visit, via Flickr user NYCTCM)

A new study from Karolinska Institute in Sweden used acupuncture as a treatment to reduce nausea in cancer patients undergoing radiation therapy. All patients received standard nausea-reducing drugs called ‘antiemetics.’

In addition, about half of the patients were given a simple acupuncture treatment several times a week. This involved having a short needle poked into their skin just above their wrists, at an acupuncture point traditionally believed to reduce nausea.

The other half of the patients received a similar treatment on the same schedule, but the needles were placed several inches away from the traditional acupuncture point, and did not penetrate the skin. Patients couldn’t tell which group they were in because the needles were encased in opaque sheathes, and the pricking sensation on the skin was basically identical.

The patients were asked daily about their experience of nausea, their expectations that the acupuncture treatment would work, and how likely they thought they were to feel nauseated in the first place. Their responses were compared to a reference group of other radiation therapy patients—not a “control group” in the strictest sense, but similar—who were treating their nausea only with antiemetic drugs.

Patients in both the “real” and “fake” acupuncture group were less likely to experience nausea than those in the reference group. Significantly less likely, in fact—in each acupuncture group only 37% of patients reported nausea, compared to 63% of patients in the reference group.

Cue the misrepresentational headlines: “Real AND fake acupuncture outperform standard medical care!”

But in fact, the study’s authors are quite clear that acupuncture itself probably has nothing to do with the results.

That’s because acupuncture, as traditionally defined, makes two claims:

  1. It matters where you put the needles;
  2. The needles need to break the skin.

In the “fake” acupuncture group, the needles were NOT placed at the traditional nausea-reducing acupuncture point; NOR did the needles break the patients’ skin. Yet the “fake” group received just as much benefit as the “real” group did.

Conclusion: Neither of the mechanisms claimed by acupuncture is responsible for the benefit the patients received.

Anna Enblom, the lead author of the study, speculated on the many other factors that could have produced a positive outcome for these patients (in this passage, ‘verum’ means ‘real’, ‘sham’ means ‘fake’, and ’emesis’ means ‘nausea’):

The verum and the sham group received extra care compared to the standard care group, which may have reduced emesis: patient-therapist communication, the knowledge that continuous contact with one single therapist would continue during the whole radiotherapy period, the tactile stimulation from the therapists’ hands, the extra time for rest and relaxation and the extra attention to the patient’s symptoms through the daily emesis questions all are important elements of this extra care.

In other words, what helped these patients was that they received extra attention from a trusted medical professional, in a relaxing, reassuring and empathetic setting. And that could just as easily be accomplished without using needles or targeting special points on the body.

Acupuncture Barbie, via Flickr user migrainechick

Another factor was that most of the patients expected their acupuncture treatment to be effective. That’s part of the placebo effect: a patient thinks she’s getting a real treatment, so her brain tricks itself into feeling like her symptoms are relieved. It works with mild symptoms, but—as Emblom points out here—”if a noxious stimulation is performed after taking a placebo pill, the study subject no longer believes in the effect of the placebo pill.” And indeed, patients who experienced nausea or vomiting were more likely to lose trust in acupuncture.

So, what this study really tells us is:

“Real” acupuncture is itself a placebo treatment.

What’s frustrating about this is that, when studied this way, acupuncture does produce better outcomes…because it is a) an extra intervention that b) patients tend to believe will be effective.

That sounds an awful lot like saying that acupuncture “works”—but that would be the wrong interpretation. What’s “working” here is everything around the acupuncture: the fact that any intervention is taking place, and the fact that the patients trust the person doing it. The improvement owes nothing at all to the “traditional” mechanisms of acupuncture.

The acupuncture is acting as a placebo—a stand-in that allows all of the elements of treatment to come into play, without actually being a treatment. Once again:

Acupuncture is placebo. That’s ALL it is.

Unfortunately we’ve seen this sort of misreporting before. There have been a number of studies that have taken this “Wrong place, fake needle” approach to studying acupuncture and come to similar conclusions. Invariably, they are reported by many major news outlets with the emphasis entirely backwards—Acupuncture – real or fake – best for back pain (MSNBC)—although there are a few places that do a proper job—Fake acupuncture as good as ‘real’ acupuncture (About.com). (I do take issue with the About.com headline; while the use of scare quotes around ‘real’ makes an ironic jab at the issue, I’d rather see a strong statement about the lack of efficacy—”as good as” confuses the issue.)

It seems to me that this nonsense is one of the drawbacks of press-release journalism, which is becoming ever more popular as newsroom budgets are slashed and dedicated specialist reporters (like science writers) are laid off. If the media relations folks writing the press releases don’t represent the research honestly, misconceptions are going to spread far and fast.

I can’t really blame someone working for a for-profit company if they try to spin their press releases as positively as they can—the system is set up to give them a compelling reason to do so. But at a scientific institution, where the goal is supposed to be the pursuit of truth and the spreading of knowledge, this kind of thing seems counter-intuitive.

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