11 October 2010

What About Those Studies?

A bright journalist asked me if acupuncture works, considering the studies that find it often doesn't work as well as a toothpick in sham studies. 

Here's one response:

Scientific deliberations take time and care. Research and inquiry functions best when taken across modalities.

Acupuncture is not placebo in that:

  1. Acupuncture works on animals--better than humans: Placebo does not work on animals. There are a quite a few veterinary acupuncturists. I can put you in touch with one, Steve Marsden, if you like. Many are like him: DVMs with secondary degrees in acupuncture, who use this modality extensively in their practice.
  2. There is no such thing as 'sham' acupuncture. There is no real 'control' in acupuncture studies.
    1. Ask any acupuncturist, and they will tell you that all the common shams--toothpicks, fake needles, and sham points--can have significant effects. Some types of acupuncture stimulate the skin without penetration, in effect the toothpick or stage-dagger needle approach.
    2. Likewise, everywhere is a point. We found ear points that the textbook locations led to fast results, while the 'sham' points--only a few millimeters away--simply had slower results noticed by patients: by about 5-10 minutes. I can show you an acupuncture text that includes more points than our beginning textbooks, used with specific purposes, that seem to cover the map. Also, there is experience from Shiatsu that has channels in between the primary ones. This matches patient experiences of pain that sometimes follow these lesser-known pathways (still different from neural ones).
    3. Some control groups are 'wait lists.' This is rarely done, though it matches the reality of chronic care. There are ethical concerns there that limit it as denying healthcare.
    4. Ted Kaptchuk has some articles on PubMed that discuss acupuncture research design and the flaws in conventional controls. However they are pretty dense and wordy articles.
    5. The only real control I've heard of are studies as the VA that apply acupuncture or not during general anesthesia of conventional surgery. However then you are looking at acupuncture in a very unusual circumstance, one which will have limited applications.
    6. Bengston did extensive research that calls into question control groups with energetic interventions, such as acupuncture, homeopathy, and the like. His surprise finding was that if an energetic treatment was applied to rats for cancers, all animals in the building registered an effect. Based on that, we now should go back through all the research to see where the control groups were located relative to one another.
    7. Scientific research on acupuncture is not correlating with clinical reality. Scientists and MDs I mention this to understand it. Conventional RCT research on acupuncture views it as if it were a drug. Instead it is more like surgery, where the issue of controls is also problematic.
  3. Acupuncture and natural medicines are applied holistically, in combination with other therapies. Acupuncture is usually combined with nutrition and lifestyle recommendations, herbs, bodywork, etc. There is a movement to "Whole Systems Research," led by Mikal Aickin, a bio-statistician. This is where treatments are analyzed in whole clinic settings. He sees huge flaws in RCT for natural medicines.
  4. Some see it that we are going about acupuncture research backwards. Hugh MacPherson in the UK came up with this: in drug studies, first we prove the drug is safe, then that it works, and then that it is cost-effective. With acupuncture, looking at safety is done last. Both he and others documented the safety of acupuncture in rigorous reviews. Compare that to aspirin and other drugs. The safety of acupuncture and natural medicines is one of its strongest aspects.
  5. For some conditions, such as chemotherapy-induced nausea, the evidence for acupuncture in RCTs is "overwhelmingly positive," in the view of one MD who now offers it to patients in oncology wards. (It's interesting to me that some of our best outcomes are for this condition, since our main acupuncture classic--the Nei Jing/Inner Classic--focused on the Stomach and digestion as well.)
  6. The research shows that acupuncture doesn't always work, but there are enough rigorous studies that document positive outcomes to say that something is going on here. That intrigues neuro-biologists and others who are focused on the mechanism of acupuncture. One PhD in that field, Richard Hammerschlag, indicates that we are about 2/3 of the way to fully understanding that mechanism. That is enough to inspire some great dialogue across professions that will lead to new discoveries. 
  7. The same meaning applies to patients. Nobody gets excited when Advil works. But if acupuncture works on a patient, they understand themselves, their bodies and their potentials in a new way. Not all of our patients may choose acupuncture, but those that do who find results are teaching others about what is possible. Research at Kaiser that was qualitative found these outcomes in natural medicines: they affected patients' worldviews and sense of self in healthy ways. Pills are not known for this. 
  8. Alternative medicine needs alternative research. Natural medicine will lead to a different research model. Integrative medicine will lead to integrative research --Aickin's Whole Systems Research is leading that. The gap between research and reality needs to be bridged.
  9. Not enough acupuncturists are involved in acupuncture research. Serious practical errors are evident as a result. This makes the treatment interventions flawed to begin with in a striking number of studies.
Bottom line for me:
  • Acupuncture is safe
  • It is cost-effective in both private and public health settings --cheaper than herbs
  • It is highly sought-after by patients
  • There is enough research to "warrant further study," as we say in research-speak, but not enough to be "conclusive."

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