Respectful Insolence

This week, the Supreme Court is hearing a case that can only be described as historic. Any of you out there (in the U.S. anyway; I realize that my readership is international) who have paid even a passing attention to the news can’t help but avoid reporting, debate, and polemics related to the Patient Protection and Affordable Care Act (PPACA), which is often disparagingly referred to as “Obamacare.” If the law is upheld, or even if most of the law is upheld, it will radically reshape health insurance in this country. Having spent 13 years in the trenches at cancer centers that see a high percentage of uninsured patients, I’ve come to the view that I hope the law is given a chance to go into full effect, because what we were doing before sure wasn’t working. Our health care system is the worst of both worlds, a fusion of the worst aspects of the free market system and a government-controlled system.

Be that as it may, if the PPACA is upheld, there will be a potential side effect that, for all the potential benefits of the new law, would be a downside. I’m referring, of course, to the parts of the law that are a little too woo-friendly. While it’s true that there are some aspects of the law that are very friendly to evidence-based medicine, such as requiring comparative effectiveness research to identify the most cost-effective and efficacious therapies and interventions, the emphasis on whole patient care, although welcome, can be easily perverted by promoters of unscientific “complementary and alternative medicine” (CAM) or “integrative medicine” modalities to allow a “foot in the door” for dubious therapies. This is exactly what we see happening right now, as I’ve been made aware of a campaign by the the American Association of Acupuncture and Oriental Medicine (AAAOM) to rally support to pressure the Secretary of Health and Human Services Kathleen Sebelius to include acupuncture as one of the “essential health benefits” that insurance must cover.

For those of you not familiar with PPACA provisions, EHBs fall into the following categories:

  • Ambulatory patient services
  • Emergency services
  • Hospitalization
  • Maternity and newborn care
  • Mental health and substance use disorder services, including behavioral health treatment
  • Prescription drugs
  • Rehabilitative and habilitative services and devices
  • Laboratory services
  • Preventive and wellness services and chronic disease management
  • Pediatric services, including oral and vision care

The specific services that must be covered as EHBs in each category have not yet been determined. In December, the Secretary of HHS released a bulletin describing the process and approach HHS will take to the rule making necessary to define what will be EHBs under the PPACA. This is a big deal, because under the law EHBs must be covered without co-pays, deductibles, or other insurance. To aid her in developing guidelines for determining what treatments should and should not be included as an EHB, HHS Secretary Sebelius charged the Institute of Medicine (IOM) with developing criteria and methods for choosing EHBs that balance effectiveness and cost. Indeed, the title of the report, released last October, is Essential Health Benefits: Balancing Coverage and Cost. As part of its report, the IOM recommended that any EHB must:

  • Be safe–expected benefits should be greater than expected harms..
  • Be medically effective and supported by a sufficient evidence base, or in the absence of evidence on ef- fectiveness, a credible standard of care is used.
  • Demonstrate meaningful improvement in outcomes over current effective services/treatments
  • Be a medical service, not serving primarily a social or educational function.
  • Be cost effective, so that the health gain for indi- vidual and population health is sufficient to justify the additional cost to taxpayers and consumers.

By these criteria, the vast majority of CAM modalities would fail miserably. However, that doesn’t stop CAM practitioners from trying to persuade Sebelius to include their favored woo as an EHB. For instance, which is exactly what acupuncturists and practitioners of traditional Chinese medicine appear to be doing. For example, here is what the AAAOM urges its supporters to do:

The AAAOM strongly supports designating acupuncture as an EHB. Our full position statement is available in the Governance section of our website at aaaomonline.org. If you are able to contribute financial support to this effort, which will be solely used to further publicize and generate action on this issue, please click here or contact us. To participate in committee work or related research projects, please contact us at info@aaaomonline.org.

Public Input is Needed: The Department of Health and Human Services (HHS) is currently accepting input regarding their approach to establishing EHBs. A strong public show of support for acupuncture as an essential health benefit will be noticed by policymakers and will lay a solid foundation for future federal acupuncture initiatives.

Take action now: Ask your patients to send an email to the address below to show their support for EHB. Also, send your own email as a patient showing your support. Emails should request that acupuncture be designated as an essential benefit service and should share the benefits of acupuncture and its cost effectiveness.

I realize that the deadline has passed in some cases

I took a look a the white paper that AAAOM has produced in support of making acupuncture an EHB. It’s chock full of the usual fallacious arguments, cherry picked science, and lists of dubious studies that I and others have deconstructed in great detail before. Adenosine study? Check. It’s there. Referral to the use of acupuncture in the miltary? (Damn you, Dr. Col. Niemtzow!) Check. It’s there. Acupuncture for migraine? Check. it’s there. And so much more is as well.

I might have to deconstruct the AAAOM position paper in detail, but that would take one of my epic Orac-length posts, or even possible more than one. So that will have to wait for a future post, either here or at my not-so-super-secret other blog. In the meantime, here’s how the government should look at EHBs. Not that it actually will look at them this way, given the political pressure that will be brought to bear to persuade them to fund woo, but this is how they should look at it. The FDA does not approve drugs or treatments that do not produce results better than placebo or sham interventions. That is a principle that almost everyone with any science-based inclination whatsoever should be able to agree on, and it’s an easy principle to explain to legislators, cabinet secretaries, and bureaucrats.

Once that principle is accepted as a starting point, there is no rationale for accepting acupuncture as one of the government-mandated EHBs because not only does it fail each and every one of the five criteria, particularly the one about being a medical intervention and not serving primarily as a social or educational intervention, but it is placebo medicine. As I have documented over the course of the last seven years as I’ve analyzed numerous acupuncture studies, when you look closely at the clinical evidence for acupuncture, it is most consistent with placebo medicine. It doesn’t matter where you stick the needles. It doesn’t even matter if you stick the needles in. (Remember the rather inconvenient study that found that twirling toothpicks against the skin actually worked better than acupuncture.) Add to that the fact that meridians don’t exist and there is no plausible physiological mechanism through which acupuncture could work, and the conclusion is inescapable: Acupuncture is placebo medicine. By policy the government does not approve placebo medicine. Indeed, there is a very long history of such a policy in the FDA and the laws that the FDA uses to regulate drugs and devices. Why should the PPACA produce a loophole through which placebo medicine can not only be given the imprimatur of government approval but be paid for by the government.

The answer is easy. It shouldn’t.

None of this, unfortunately, means that the government will actually be consistent in this, unfortunately. With interest groups like the AAAOM and many others lobbying the HHS and woo-friendly legislators like Senators Tom Harkin and Orrin Hatch doing everything in their power to promote “holistic” modalities based more on magical thinking than science. From a science-based standpoint there’s a lot to like in the PPACA, particularly the parts that emphasize developing evidence to identify the most effective treatments. However, how those parts of the law are interpreted and what rules they result in are everything.
Whenever politics is involved, there’s no guarantee that when the rubber hits the road evidence won’t mean as much as the law says it should.

Comments

  1. #1 Shay
    March 27, 2012

    I’m still trying to wrap my brain around the announcement last week that someone in the Surgeon General’s office is pushing a “partnership” between an organization called Acupuncturists Without Borders and the Medical Reserve Corps.

    I really didn’t wonder when the Air Force climbed onto the acupuncture bandwagon (ok, I’m a retired Marine. Nothing the Air Force does surprises me), but the Surgeon General’s office?

    Plow me under and call me breathless.

  2. #2 prn
    March 28, 2012

    There may be lots of opportunities for cost cutting cancer treatment. My experience is radically different, and cheaper, than “standard” – it is far more technically based but with generic substances and DIY participation and responsibility.

    My expectations for any future US government program are low. Half the problem with woo based medical education is that geriatric failures are societally cheaper. It’s not too much watching Soylent Green and Logan’s Run, history repeatedly shows that the older crowd take a drubbing during financial crises.

  3. #3 prn
    March 28, 2012

    There may be lots of opportunities for cost cutting cancer treatment. My experience is radically different, and cheaper, than “standard” – it is far more technically based but with generic substances and DIY participation and responsibility.

    My expectations for any future US government program are low. Half the problem with woo based medical education is that geriatric failures are societally cheaper. It’s not too much watching Soylent Green and Logan’s Run, history repeatedly shows that the older crowd take a drubbing during financial crises.

  4. #4 shawmutt
    March 28, 2012

    Just a little note, the term “Obamacare” is being embraced by the Obama team–at least if the emails I receive from their folks is any indication.

  5. #5 jane
    March 28, 2012

    Sadly, there are quite a lot of clinical trials supporting use for musculoskeletal problems, and some suggestive evidence in favor of other uses. I know you care nothing for anecdotes (unless the phonied-up Toothpick Study counts) but I have a dear friend who was recently seeking cardioversion for persistent atrial flutter. He was supposed to take warfarin for weeks before the procedure, and he was getting endlessly dicked around being given doses that were not adequate for someone on a plant-based diet then told his INR wasn’t high enough to count. There’s a placebo-acupuncture-controlled Italian acupuncture study that showed reduced recurrence of persistent atrial fibrillation after cardioversion and a Chinese study that showed greater natural resolution of paroxysmal AF compared to amiodarone. Acting on that knowledge, he went in the meantime to start getting acupuncture treatments that he hoped would help him stay in sinus rhythm if he ever got his cardioversion. Two sessions later, what do you know, he was back in sinus rhythm for the first time in months, with no need to keep jumping through the cardio’s hoops. Sure, maybe it was a coincidence, and the benefit vs. placebo was magically just a placebo effect – but I can pretty much tell you acupuncture is going to be part of his treatment plan as needed in future.

  6. #6 Lawrence
    March 28, 2012

    @jane – I would be interested in what you think the physical interactions between the needles & someone’s heart is, because I have a hard time trying to figure out what the actual physical process is supposed to be there.

  7. #7 Todd W.
    March 28, 2012

    @jane

    Got links to those two studies? Or, at the very least, titles and authors?

    It may have been placebo effects. It may simply have been coincidence. There is also a remote possibility that there really was a legitimate effect, but the likelihood of that is vanishingly small. The problem with anecdotes like that is that, well, first of all, you have a sample of 1. Nothing to compare to to determine what had the effect. Second is that it’s all in the past, most likely with no additional evidence available that is independent from the person recounting the scenario. That means that there could also be recall bias.

    At any rate, especially given that numerous studies have shown no difference between needles actually breaking the skin and toothpicks or sham needles that don’t, there is no ethically justifiable reason to include acupuncture under any health coverage. If the performance is the same, but the real skin-puncturing needles carry the increased risk of infection or organ perforation, then the risk:benefit analysis would automatically nix it.

  8. #8 Denice Walter
    March 28, 2012

    Life is certainly not easy so I like to inject a dose of levity every now and again:
    today Mike Adams ( Natural News) trying to be clever, invokes laughter through the paucity of his feeble attempts to ridicule Obamacare- which is a “limitless expansion” of the government telling you what to buy- ludicrous examples follow.

    You see, there is a difference between tyrants and entrepreneurs, he tells us: “tyrants FORCE you buy while entrepreneurs leave it up to you and free choice”. Funny, I can think of other ways to differentiate the two.

    “This is how national economies are destroyed.”
    Mike now rests upon his laurels, health ranger, scientific rebel with a cause and economic doom prognosicator *par excellence*-
    Roubini must be jealous.

  9. #9 Mattand
    March 28, 2012

    This comment is probably too political for this blog, but oh well: in all likelihood, the PPACA is going to fail.

    The current Supreme Court leans conservative and will for several years, possibly a decade or two. Given the current mindset among many conservatives that whatever Obama proposes must be defeated at all costs, I honestly can’t see this going anywhere.

    I’d like to think that the SCOTUS is above all of that, but I’m not optimistic.

    What’s ironic about all of this is the personal mandate started life a conservative response to the Clintons’ initial attempt to reform health care and was actually enacted by Romney in MA.

    The law may not be perfect and while I personally have problems with the individual mandate, it’s something that needed to be addressed. Given the near hysteria over Obama among event the most rational of conservatives, this issue isn’t going to be resolved any time soon.

  10. #10 Mattand
    March 28, 2012

    Make that “Given the near hysteria over Obama among even the most rational of conservatives,”

    I hate blog software with no editing functions. Must proofread better.

  11. #11 Shay
    March 28, 2012

    I’m all for a patient understanding his/her medical issues and working with the medical professionals towards a common goal.

    But I have the same problems with DIY cancer cures that I do with DIY car repair. I don’t have the training, tools or experience necessary to fix my car and the consequences of my screwing up, say, a brake adjustment, are too dire to be worth the risk.

    I am not going to second-guess someone who has attended school, takes refresher training, has invested in the technologically-advanced equipment required, and … well… you know, does this for a living.

  12. #12 Shay
    March 28, 2012

    Sorry, that last post was in response to prn@2.

  13. #13 jane
    March 28, 2012

    ToddW – I don’t post links, as it triggers the spamguard without meaningfully affecting the conversation. By searching PubMed you can find:

    Lomuscio A, Belletti S, Battezzati PM, Lombardi F. Efficacy of acupuncture in preventing atrial fibrillation recurrences after electrical cardioversion. J Cardiovasc Electrophysiol 2011;22:241-7.

    Xu HK, Zhang YF. [Comparison of therapeutic effects of acupuncture and intravenous injection of amiodarone in the treatment of paroxysmal atrial fibrillation and atrial flutter.] Zhongguo Zhen Jiu 2007;27:96-8.

    My friend’s experience may indeed have been a coincidence, but it wasn’t recall bias; this happened in the past month and I heard what was going on as it happened, including that he was starting acupuncture while he was still in AF. Now, I wouldn’t suggest that insurance should start covering acupuncture for AF, unless and until more clinical trials replicate the effect. However, my friend’s personal experience certainly gives him adequate reason to try it again if his condition recurs (as is likely in the long term). If it works a second time, that will give him enough evidence to use it a third time. He, like me, feels no philosophical obligation to refuse something that appears to offer him a major health benefit just because it has not been proven beyond doubt.

    Acupuncture may well, as you say, prove not to require the physical penetration of the skin. But if that is the form of treatment that is generally available, and if that form of treatment is safer and more effective than conventional treatment (as appears to be the case for some musculoskeletal problems), most will see no need to avoid it because of the ludicrously low risk of “organ perforation.” The risk of organ perforation from long-term aspirin or NSAID use is several orders of magnitude higher, in the form of hemorrhaging gastric ulcers.

    Lawrence – I dunno. A sizeable number of clinical trials, including one published in JAMA, have found that moxibustion is effective in turning breech fetuses (allowing the mother, if American, to avoid a compulsory C-section). The traditional method involves burning stuff on the little toe. Before reading the JAMA study, I would have bet a good sum of money that this could not work, but the difference between treatment groups was huge. Acupuncture needles certainly have no physical effect on the heart, but they do affect the nervous system, which affects the brain, which affects the nerves that are connected to the heart; and I understand that AF is thought to begin as a nerve-related problem in many people.

    There are two totally different questions here: Does a treatment work (for a particular use, in a particular type of patient), and if so, how does it work? Some people have a philosophical attitude that they should not use an effective treatment if the mechanism is not understood; others insist, at least in some circumstances, that if mechanism is not understood, the treatment must not work at all! Most people only care about how much net benefit they can expect. If acupuncture does work, sorting out the mechanism(s) ought to be very interesting for scientists, but not for the public.

  14. #14 Roadstergal
    March 28, 2012

    today Mike Adams ( Natural News) trying to be clever, invokes laughter through the paucity of his feeble attempts to ridicule Obamacare

    Well, I’ve heard that laughter is the best medicine. Will Adams’s loopiest screeds be covered as an EHB? ;)

  15. #15 Beamup
    March 28, 2012

    There are two totally different questions here: Does a treatment work (for a particular use, in a particular type of patient), and if so, how does it work? Some people have a philosophical attitude that they should not use an effective treatment if the mechanism is not understood; others insist, at least in some circumstances, that if mechanism is not understood, the treatment must not work at all! Most people only care about how much net benefit they can expect. If acupuncture does work, sorting out the mechanism(s) ought to be very interesting for scientists, but not for the public.

    This is an inaccurate description. The actual position is that if a treatment either has a large amount of evidence demonstrating that it DOES NOT work, or substantial basic science demonstrating that it CANNOT work, then the evidence in favor of the treatment must be of sufficient amount and quality to offset the evidence against. Simple lack of knowledge of a mechanism is not used as evidence against; affirmative evidence that a mechanism does not exist is. “I don’t know how this works” is one thing, “I would have to discard most of what’s known about biology in order to make it even possible for this to work” is quite another.

    In the case of acupuncture, there is overwhelming basic science demonstrating beyond a shadow of a doubt that the proposed mechanism is utterly false. There is strong basic science indicating that [i]any[/i] mechanism is highly unlikely. There is a mountain of high-quality experimental evidence directly showing that there is no therapeutic effect beyond placebo.

    In the face of all that, small low-quality studies (which are the ones which tend to give positive results) quite simply mean nothing. They cannot hope to stand against the weight of contrary evidence.

    If there were sufficient large, high-quality studies demonstrating efficacy beyond placebo for a particular indication, then it could be accepted. But said studies simply do not exist. And even if they did exist for (say) turning a breech baby, that would have no applicability whatsoever to migraines – because the claimed reason to believe there’s a link between those is conclusively proven false.

  16. #16 Beamup
    March 28, 2012

    An analogy…

    If I claim that coating a solar cell with a particular material improves its efficiency, but I don’t know why, that is not implausible. Things in that general space do affect the efficiency of a solar cell, so there’s no particular reason to believe it CAN’T happen even if we don’t know exactly why. So this probably doesn’t need more evidence than setting up the coated and non-coated cells next to each other and measuring the output.

    If I claim that leaving half of the solar cell in the shade, with the other half in the light, produces dramatically more energy than illuminating it all, that is pretty implausible. It runs completely counter to everything known about solar cells, and many experiments have already been done which would have seen such an effect if it existed. Pretty hard to believe, but if hundreds of different research groups around the world try it, very carefully, and every single one of them confirms the same result, it would be accepted (and set off a big search for why it works).

    If I claim that I can take away the solar cell, just leave the leads which would have connected to it, and that will produce thousands of times the energy the solar cell itself did, then nobody’s going to buy it unless I can prove that energy isn’t really conserved.

    Acupuncture is essentially in the same situation as the half-shaded solar cell. (Homeopathy or reiki are the third case.) Jane is equating it with the first case, which is simply not the case.

  17. #17 JGC
    March 28, 2012

    I think it needs to be pointed out that the Lomuscio et al’s “Efficacy of acupuncture in preventing atrial fibrillation recurrences after electrical cardioversion” was a poster presented in the fifth poster session of the Heart Rythym 2010 conference–not an article submitted to J Cardiovasc Electrophysiol and submitted to standard peer review before publication. Caveat emptor

  18. #18 JGC
    March 28, 2012

    Haven’t been able to track down anything re Xu paper other than an abstract (at least, not in English) but the abstract indicates they didn’t control for placebo effects associated with acupuncture treatment: they split the subjects into two groups, one received amiodarone and one recieved accupuncture, but they failed to include no teatment or sham accupuncture control groups.

    All told I find these citations less than compelling evidence for the efficacy of treating AF with acupuncture.

  19. #19 jane
    March 28, 2012

    Beamup – I’ve learned the hard way that there’s no use in supplying lists of references, but those who have really investigated this subject have found that (1) many studies comparing acupuncture to “placebo acupuncture” used placebo acupuncture methods that could have equally stimulated the nervous system (e.g., poking someone with Toothpicks), and (2) despite that, more than a few of those studies find real acupuncture to be better than placebo acupuncture. So the situation is not cut-and-dried as you seem to believe.

    Moreover, if acupuncture were Only A Placebo, there is the question of how it can perform better than an active conventional treatment in head-to-head trials. Do analgesic drugs not also have placebo effects? If the only-placebo effect of acupuncture somehow manages to be more potent than the chemical-plus-placebo effect of a drug, why is a person bad or stupid for preferring the former? And in most of those cases, patient pain is the measured variable and everyone agrees that placebo effects can be significant. Most authorities would doubt that the placebo effect can correct one’s heart rhythm, as JGC suggests. (But if it could, I would want to use that, rather than avoid it.)

    You argument that “the” mechanism has been disproven is irrelevant. The ancient Greeks thought that opium relieved pain through rebalancing of humors. Now that we know that the humoral theory is “utterly false,” does it follow that opioid drugs “CANNOT” work? No, the truth is that people have through the ages managed to discover many real phenomena without having the least correct understanding of the causes of those phenomena, and inevitably tried to fill in with incorrect explanations. I believe that there is no such thing as qi, and that acupuncture works by affecting the incredibly complex nervous system in some way we don’t understand. If you insist that that is impossible, you imply that favorable acupuncture studies are evidence for the existence of qi!

  20. #20 Horvendile
    March 28, 2012

    So acupuncturists are going to lobby to get covered. Of course they are as will many other treatments and drugs that aren’t effective. There’s nothing wrong with that. If congress was saying “let’s override the effectiveness criterion because we are declaring by fiat that acupuncture is effective” I’d be worried. To deny them the right to lobby is to declare by fiat that it is ineffective. Might there be errors made? Of course there will be. Effective treatments will be denied and ineffective ones approved because people make errors and just random chance. You do the best you can and keep making corrections as you go along. You aren’t going to get perfection.

  21. #21 kruuth
    March 28, 2012

    What is so worrisome about declaring something effective by fiat is that something can be declared ineffective in the same manner. All you need is some woo-meister like Rath or someone with deep enough pockets to get something like HIV meds replaced with vitamin C.

  22. #22 g724
    March 28, 2012

    Yes, we *should* cover acupuncture, and Reiki (did I spell that right?) and crystal energy healing with super-powerful magic spells included.

    Cover all of that stuff, with the requirement for meticulous data collection, with regular MDs in charge of it.

    It won’t take long to sort the chaff from the dog doo.

    But what I think could be interesting, is that with enough data, there might turn out to be different types and degrees of placebo responses, and there may be a pattern there that can be made use of for at least palliative measures. For example what about the following:

    “I’m going to start you out on a weak placebo twice a day. If this isn’t enough to get a decent placebo response, we’ll move up to a stronger one next week.”

  23. #23 Rose
    March 28, 2012

    How sad. Right now, many insurance plans can exclude prenatal and maternity care. And they almost never cover things like specialized hearing aids for those of us with severe hearing impairments that require expensive ($3K) hearing aids. But we are supposed to find money for acupuncture and Chinese herbs??? Let’s put our limited health care dollars into things that actually WORK.

  24. #24 Navigator
    March 28, 2012

    yes, it’s sad. Why is healthcare decided by what’s popular, and trendy, and what’s the current happy jack? Why is science left in the dust? If we, as the public, are paying for this with our tax dollars, why not use science as the standard?
    I was appalled to find out last month that my VA hospital was providing accupuncture and…wait for it…craniosacral therapy. I mean really, who decided this?
    And of course it is impossible to follow the line of reasoning, find out who made the decision, etc.

  25. #25 Michael
    March 28, 2012

    @Denice Walter- there ARE legitimate arguments against the mandate. A contract can’t truly be said to be voluntarily entered into if the government will fine you if you don’t have SOME insurance. Some countries had laws which obligated citizens to work- these laws were often abused to force people into jobs they didn’t like. Of course, the mandate is different from such laws, and without it, there’s a “free rider” problem. It’s a complicated issue.

  26. #26 Nibi
    March 28, 2012

    Navigator

    If we, as the public, are paying for this with our tax dollars, why not use science as the standard?

    Unfortunately it seems that we, the tax paying public, are demanding that our healthcare system cover this quackery. I work for a private corporation that has a health care plan that currently covers acupuncture because there is enough employee demand for this shit. As long as there is sufficient popular demand, dollars will be sucked out of our healthcare system to pay for this nonsense regardless of whether it is through private insurance or a taxpayer funded system.

  27. #27 Mojo
    March 29, 2012

    @jane:

    Most authorities would doubt that the placebo effect can correct one’s heart rhythm, as JGC suggests.

    Surely the placebo effect affects the brain?

    One of your arguments for the efficacy of acupuncture is that acupuncture needles “affect the nervous system, which affects the brain, which affects the nerves that are connected to the heart”. If “acupuncture works by affecting the incredibly complex nervous system in some way we don’t understand”, why shouldn’t the placebo effect do the same?

  28. #28 jane
    March 29, 2012

    Mojo – The placebo effect as a known culturally mediated psychological effect (as opposed to the play of chance) is related to endogenous opioids. If you cause someone to experience a placebo effect, then give naltrexone (an opioid antagonist) the placebo pain relief goes away. This mechanism is generally thought to affect only the perception of pain and not the course of any underlying disease the person may be suffering. That is the only rational argument for objecting to placebo-related relief: the patients may FEEL better, but they aren’t REALLY better, so they are not being well served. But then there are people who will turn around and say that when an herb normalizes liver enzymes (even in a placebo-controlled study) that must be the placebo effect. Well, what are the limits to this power.

  29. #29 Beamup
    March 29, 2012

    I’ve learned the hard way that there’s no use in supplying lists of references, but those who have really investigated this subject have found that (1) many studies comparing acupuncture to “placebo acupuncture” used placebo acupuncture methods that could have equally stimulated the nervous system (e.g., poking someone with Toothpicks)

    Which might be a credible argument if there was any evidence for an actual effect, but even at its best doesn’t support acupuncture. Even assuming arguendo that tapping toothpicks has therapeutic value, that just makes it even more unethical to risk infection, organ puncture, etc. when the effect could be elicited without that risk.

    But until there’s actual credible evidence that an effect exists (which there isn’t), you’re just speculating about why the Tooth Fairy left more money for a molar than an incisor.

    (2) despite that, more than a few of those studies find real acupuncture to be better than placebo acupuncture.

    The smaller, lower-quality ones, yes.

    So the situation is not cut-and-dried as you seem to believe.

    If the entire body of the literature is examined, yes, it is.

    Moreover, if acupuncture were Only A Placebo, there is the question of how it can perform better than an active conventional treatment in head-to-head trials.

    There are variations in the strength of placebo effects, and placebo arms in trials are subject to many other biases.

    You argument that “the” mechanism has been disproven is irrelevant.

    Far from it – that fact obliterates whatever prior probability the hypothesis had. There are two reasons to consider something a credible treatment to study – either there’s a mechanism by which it might work (false for acupuncture) or there’s credible evidence of effect (also false for acupuncture). The combination means that swinging a yo-yo around a person’s head is just as credible a treatment as acupuncture. More so, in fact, since yo-yo swinging hasn’t been repeatedly shown to have no effect beyond placebo.

    Now that we know that the humoral theory is “utterly false,” does it follow that opioid drugs “CANNOT” work?

    False analogy; even if we had no explanation of a mechanism it’s well-established that ingesting particular chemicals can have physiological effects. No implausibility there.

    I believe that there is no such thing as qi, and that acupuncture works by affecting the incredibly complex nervous system in some way we don’t understand.

    And people believe the Earth is flat. In the absence of EVIDENCE that acupuncture works at all, and the presence of affirmative evidence that it does not work, speculating about WHY it works is just silly.

  30. #30 Denice Walter
    March 29, 2012

    @ Michael:

    While there may be reasonable arguments against the mandate, they certainly aren’t going to be articulated by Mike Adams:

    the major point of most of his rants involve *any* governmental control over health care and related issues-
    he carries on about restrictions on (untreated) ‘raw milk’, fluoridation, airline passenger screening and vaccination for school entry. Getting his audience angered over “governmental oppression” and “loss of rights” is his MO as a ‘health freedom fighter’ or whatever he’s calling himself this week. In the long run, it all boils down to the fact that regulations restrict his business- selling supplements, foods and health advice.

    Believe me, it’s not about realistic arguments and measured opinion in his case. Check out his cartoons about governmental officials, pharma and doctors.

  31. #31 Beamup
    March 29, 2012

    Another point I forgot to make. As mentioned, even if we assume that tapping toothpicks has therapeutic value, that doesn’t justify acupuncture due to the greater risks associated with actual needling.

    The other side of that same coin is that acupuncture is structured and optimized to “unblock the flow of qi,” not to maximize whatever benefits there might be to toothpick-tapping. Hence it’s overwhelmingly likely that it could be improved upon. So acupuncture AGAIN completely fails.

  32. #32 JGC
    March 29, 2012

    Most authorities would doubt that the placebo effect can correct one’s heart rhythm, as JGC suggests.

    Which authorities have you subsumed within that ‘most’, exactly? I’m unaware that medical professionals dispute the fact that adinistrating placebos can cause actual physiological changes (after all, it’s for precisely this reason that properly designed clinical trials, including those that don’t rely personal reporting for scoring treatment success, include placebo arms.)

  33. #33 jane
    March 29, 2012

    Er, no, actually, it’s not. There is no obvious connection (or known mechanism with high prior probability, as certain of your cohorts might put it) between endogenous opioids and long-term effects on most disease processes. If the placebo effect could make cancer regress, that would make it very rational indeed to rely on Essiac rather than cut-burn-and poison. Sadly, it doesn’t, and nobody with sense even suggests that it does. The primary reason why clinical trials with hard endpoints have “placebo” groups is that for any disease, some people will remain stable or get better with zero treatment and some will get worse, and one wants to know that the treatment group does better than a control group. You cannot use data from an older untreated patient population, because they probably will not be comparable in all ways to the group at hand. The secondary reason, in the case of a double-blind study, is to try to limit the ability of investigator bias to influence the results.

  34. #34 JGC
    March 29, 2012

    You will agree, then, that as Xu et al lacked any placebo control it’s impossible to determine if the observation that those recieiving accupuncture resolved AF as well or better than amiodarone was in fact a result of the accupuncture treatment delivered, a result of these subjects getting better for reasons other than accunpuncture, or a result of investigator bias influencing the results–right?

    Or is this some unique instance where we need not be concerned about these possibilities?

  35. #35 lilady
    March 29, 2012

    Jane…I found some websites that discuss ONE of the acupuncture studies you reference, but many Alt/Cam websites that prominently feature BOTH of the studies that you referenced.

    I know you didn’t want to link to the acupuncture studies…but could you provide us with the web link or website, where you found both studies?

  36. #36 jane
    March 29, 2012

    lilady: Since I stated before that I found them on PubMed, I suspect you of trying to set up some sort of ad hominem.

    JGC: While Americans tend to prefer study designs with one active treatment and one placebo control (among other things, you avoid accidentally demonstrating that your new me-too drug is worse than an off-patent generic), many foreign scientists favor trials that pit one putative active treatment against another to see which, if either, is better. If you want to suggest that the ideal trial design would be three-armed (new treatment, old treatment, and placebo), well, I would agree with you, but for reasons of statistics and cost, almost nobody does that.

    As for this trial, the “standard” treatment arm, amiodarone, is generally accepted to be anti-arrhythmic, and since it is a terribly toxic drug, you would not expect it to be used if there were no evidence of its efficacy. However, I do suppose it is conceivable that the patients in the amiodarone group in that study were LESS likely to spontaneously revert to sinus rhythm than they would have been had they just been left alone. Or given a sugar pill. If there’s any question about that whatsoever, both Chinese and American doctors should most certainly stop using amiodarone for AF. (BTW, I am not interested in producing a full review of the clinical trials of amiodarone at this time, so if you want evidence that it is a known anti-arrhythmic or that it is used to treat AF, I suggest that you search PubMed.)

  37. #37 lilady
    March 29, 2012

    @ Jane:

    “I know you care nothing for anecdotes (unless the phonied-up Toothpick Study counts) but I have a dear friend who was recently seeking cardioversion for persistent atrial flutter. He was supposed to take warfarin for weeks before the procedure, and he was getting endlessly dicked around being given doses that were not adequate for someone on a plant-based diet then told his INR wasn’t high enough to count. There’s a placebo-acupuncture-controlled Italian acupuncture study that showed reduced recurrence of persistent atrial fibrillation after cardioversion and a Chinese study that showed greater natural resolution of paroxysmal AF compared to amiodarone.”

    I know you don’t care much for anecdotes, but my husband had atrial flutter/tachycardia S/T acute onset Epstein Barr Virus (elevated liver enzymes, ascites and positive serum early antigen EBV). He was eligible for cardio-version and returned to normal sinus rhythm. He did not require amiadarone and was prescribed a beta-blocker.

    June, 2005, he was in A-flutter with tachycardia and underwent minimally invasive R. atrial ablation and continued beta-blocker medication, along with warfarin-maintained with therapeutic range. Warfarin was withdrawn within 6 months.

    After four more years, he was in A-Fib and underwent minimally invasive L. atrial ablation, remained in the hospital for 3 days while sotalol was induced:

    http://www.drugs.com/pro/sotalol.html

    He was released from the hospital with sotalol, the beta-blocker, warfarin and heparin (prescribed until warfarin was in therapeutic range-then discontinued). The warfarin was discontinued after 1 year, just before he was weaned from the sotalol.

    I don’t understand how you can state that an acupuncture needle placed along the pathway of a *yin* meridian can have a calming effect on the brain…which in turn affects sinus rhythm, tachycardia, A-flutter and A-Fib:

    http://acupunctureberkeley.net/learning-more-about-acupuncture-meridians/

    Jane, I think you have put the cart before the horse here:

    http://www.a-fib.com/Overview.htm

    See the section Stroke Risk:

    STROKE RISK
    If you have A-Fib, how sick are you? A-Fib may feel weird and can be very frightening, but an attack of A-Fib by itself usually isn’t life threatening (with the exception of a very rapid, irregular heart rate as mentioned above). The biggest danger from A-Fib is stroke.Graphic of Heart and EKG Because your heart isn’t pumping out properly, blood can pool in your atria, particularly in the Left Atrial Appendage. Blood clots can form and travel to the brain causing stroke.
    If you have A-Fib and aren’t being treated by a doctor, you are five-to-six times more likely to have a stroke than the general population.106 Researchers estimate that 35% of patients with A-Fib will suffer a stroke107 (unless treated). A-Fib is responsible for up to 25% of all strokes, or 140,000 strokes annually.235
    An A-Fib stroke is worse than other causes of stroke. Half of all strokes associated with atrial fibrillation are major and disabling.168 23% of A-Fib stroke patients die, and 44% suffer significant neurologic damage. This compares to only an 8% mortality rate from other causes of stroke.132, 166 Strokes in women are more disabling than in men.245
    There is also a danger of “silent” A-Fib strokes where stroke effects aren’t evident but may appear like attention deficit, forgetfulness, and senile dementia.72 Silent A-Fib is common. Up to 30% of A-Fib patients are unaware they have A-Fib.140 25% of those who suffered an A-Fib stroke had no prior diagnosis of A-Fib.141,142

    A-Flutter and A-Fib can affect the brain, Jane…in the form of strokes and increased risk of dementia.

    Why don’t you send this site to your *friend*?

  38. #38 Ender
    March 30, 2012

    Re: moxibustion for breech babies – the results may not be as clear cut as suggested:

    http://www.reuters.com/article/2009/10/29/us-chinese-medicine-idUSTRE59S41C20091029

  39. #39 herr doktor bimler
    March 30, 2012

    From Ender’s link:
    “a midwife trained in acupuncture”…
    These are five very scary words.

  40. #40 Mojo
    March 30, 2012

    @jane

    You are arguing that acupuncture might work because it “affects the brain, which affects the nerves that are connected to the heart”, “by affecting the incredibly complex nervous system in some way we don’t understand”. You are also arguing that it is improbable that the placebo effect can have an effect on the heart.

    Do you deny that the placebo effect affects the brain? If acucpuncture can affect the heart via its effect on the brain, why shouldn’t the placebo effect also do this “in some way we don’t understand”?

    The thing is, once you start claiming that something “works by affecting the incredibly complex nervous system in some way we don’t understand” you can’t exclude any other cause, such as the placebo effect, also operating “in some way we don’t understand”.

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