Pulse debate on acupuncture – Part II

My contribution to the debate at Pulse on 17 June 2009 is reproduced below. At the Pulse site you can read the counter-piece by Dr Andrew Hamiton who supports acupuncture. 

A few years ago I thought there might be something in acupuncture and I was keen to exploit its potential to help my patients. Unfortunately, my personal experience of a medical acupuncture course left me feeling like I had been sold a timeshare or indoctrinated into a cult. The evidence was brushed aside and selectively quoted by GPs in a feverish atmosphere of enthusiastic and misguided holism. I was not impressed and I became sceptical.

Let’s put aside the traditional acupuncture mumbo-jumbo of chi and meridians to consider, as pragmatic GPs, the simple question: does it work?

In the past, it’s been difficult to do trials with realistic placebos and this is undoubtedly part of the reason for the persistence of the belief that acupuncture is a useful medical intervention. The challenge is to separate the real effects of acupuncture from placebo. It’s important to remember that patients inevitably receive more attention, including lifestyle advice and support, when spending time with any therapist. This all tends to get lumped in as the ‘placebo effect’ and helps explain why even sham acupuncture can show benefit over standard care.

A recent large trial compared acupuncture versus toothpicks touched against the skin in patients with chronic low back pain. There was no difference between the acupuncture and toothpick groups. All these groups, even the toothpicks, did better than standard care, and most right-minded folk would confidently call this a placebo effect.

Acupuncturists claim, with no apparent trace of embarrassment, that this represents a trial in acupuncture’s favour and that needling site and even penetration may be less important than thought. In effect they are suggesting that toothpicks are some kind of acupuncture-lite. I would suggest that toothpicks are patently not acupuncture and that this is strong evidence that acupuncture itself is ineffective.

Another recent trial of acupuncture for hot flushes in menopausal women claimed an impressive effect. But there was no attempt at any placebo control and the outrageous bias in the sample practically guaranteed a positive result. Even with these loaded dice the differences found may have been statistically significant but were clinically minimal. The press releases, duly reported by time-pressured news desks, trumpeted the success of acupuncture for alleviating hot flushes.

A casual and selective approach to evidence, allied to vigorous self-promotion, is a hallmark of the acupuncture lobby’s approach to the literature.

Acupuncture relies on the faith-based collusion of expectation between acupuncturist and patient. Its promotion also feeds into a choice culture capable of overriding common sense in many areas of general practice and that rides roughshod over the medical evidence. Some GPs may shrug and suggest there is no harm in it but I feel uncomfortable sitting back as acupuncturists spend an estimated £32 million of precious NHS funds.

Acupuncturists have an emotional investment in this therapy. They are fervent, enthusiastic advocates who almost certainly have nothing but good intentions. But they are performing contortions when describing these trials and to justify the continued use of acupuncture in the face of mounting evidence that it is nothing more that a dramatic placebo.

Acupuncture has been touted as a panacea for 4,000 years and it may have been used by countless millions around the globe but no one, in that whole time, has proved beyond any reasonable doubt that there is a clinically significant effect that can be distinguished from bias. We would have flushed away any drug with such poor results. It’s time that acupuncture was consigned to the sharps bin.