Field of Science

Acupuncture infiltrates the University of Maryland and NEJM

This is embarrassing. In a recent article in the New England Journal of Medicine, Brian Berman from the University of Maryland argues why acupuncture should be recommended for patients with lower back pain. In the very same article he and his colleagues explain that the evidence shows that there is no difference between real acupuncture and sham acupuncture. That’s right: it doesn’t matter where you place the needles, or even if you puncture the skin. Even toothpicks will give the same effect. Any good scientist would conclude, obviously, that acupuncture doesn’t work.

But not Dr. Berman. Or (to give proper credit) his co-authors, Drs. Langevin, Witt, and Dubner.

Without a hint of irony, Berman and colleagues describe how
“Internal disharmony is believed to cause blockage of the body’s vital energy, known as qi, which flows along 12 primary and 8 secondary meridians. Blockage of qi is thought to be manifested as tenderness on palpation. The insertion of acupuncture needles at specific points along the meridians is supposed to restore the proper flow of qi.”
Note the careful wording: they write “is believed to cause” and “is supposed to restore.” Perhaps they don’t believe it themselves? Maybe they’ll explain later that this pre-scientific magical thinking has no place in modern medicine, and no basis in biology, physiology, physics, or any other science.

Nope! Instead, they say
“Efforts have been made to characterize the effects of acupuncture in terms of the established principles of medical physiology on which Western medicine is based. These efforts remain inconclusive, for several reasons.”
How about this reason: there’s no effect, therefore nothing to explain. Perhaps Berman missed that first-year course in logic.

Let’s be clear: acupuncture is pseudoscience. It’s based on magical thinking about a non-existent “life force” that has never had one whit of evidence to support it. The only benefits are placebo effects, as the sham acupuncture experiments demonstrate. The notion of “meridians” that can be somehow fixed by sticking needles into the skin is laughable. (A 2000 review article concluded that meridians and acupuncture points simply don’t exist.) Berman’s article attempts to give acupuncture credibility by pointing to studies that show, for example,
“Acupuncture has been shown to induce the release of endogenous opioids in brain-stem, subcortical, and limbic structures.”
Without getting into the details (most of these studies are poorly done), it’s no surprise that sticking needles into the skin causes a physiological effect. Duh!

Berman has gone to great lengths to try to show that acupuncture works. One of the studies he cites is his own NIH-funded study of “electroacupuncture”, a treatment that involves sticking in needles and then applying an electrical current. (One wonders how the “ancient” Chinese acupuncturists managed to plug in their needles.) To demonstrate that electroacupuncture releases hormones, they tortured some rats – nearly electrocuted them, in fact. To quote from the study:
“EA [electroacupuncture] intensity was adjusted slowly over the period of approximately 2 min to the designated level of 3 mA, which is the maximum EA current intensity that a conscious animal can tolerate. Mild muscle twitching was observed.”
But hey, what’s wrong with a bit of rat torture in the name of pseudoscience?

Why do I say this is embarrassing? Well, I’m a professor at the University of Maryland. I’m not at the the School of Medicine (where Berman is), which is an independent campus in Baltimore, quite distinct from the much larger main campus in College Park, where I work. But when the headline says “University of Maryland”, it reflects on all of us. And while I can’t prevent Dr. Berman from promoting pseudoscience, at least I can make it clear that he’s not speaking for me.

Dr. Berman is the recipient of millions of dollars in grants from NIH’s National Center for Complementary and Alternative Medicine (NCCAM) (here's one). It’s no surprise, then, that Berman concludes his NEJM article by calling for more research into acupuncture:
“It may also be important to try to identify the optimal candidate for acupuncture on the basis of individual beliefs, expectations, and psychological profile.”
In other words, let’s see if particularly gullible people might be more willing to tell us that acupuncture works. He recommends other studies too, presumably to be funded by NCCAM. Berman’s work is an example of why I have repeatedly called on Congress and the President to eliminate NCCAM. NCCAM’s annual budget of $129 million is an appalling waste, and after >15 years and >$2 billion in funding, it has yet to prove the efficacy of a single “alternative” treatment.

After reviewing the research and acknowledging out that sham acupuncture is just as effective as “real” acupuncture, Berman and colleagues recommend how to treat a hypothetical patient with chronic lower back pain:
“We would suggest a course of 10 to 12 treatments over a period of 8 weeks from a licensed acupuncturist or a physician trained in medical acupuncture.”
This is astonishing: they just finished explaining that acupuncture doesn’t work any better than sham treatment. So why go to a “licensed” acupuncturist, since you can use toothpicks that don’t puncture the skin and get the same effect? Toothpick acupuncture won’t cost $125 per session (that’s $1000 for Berman’s recommended treatment), and it doesn’t carry the very real risk of infection. Based on the evidence reviewed in their own article, Berman et al. are recommending a treatment that seems to border on malpractice.

I hasten to add that the University of Maryland at Baltimore (not my campus!) has many outstanding scientists and excellent research programs. But UMB seems happy to support this rotten apple in its midst (as does NEJM, I should add). It issued a press release about Berman’s article in which Albert Reece, Dean of the medical school, says
“Dr. Berman and his team at the University of Maryland Center for Integrative Medicine are international leaders in the field of integrative medicine; they are among the many innovative, world-class researchers at the University of Maryland School of Medicine.”
I’m afraid I’ll have to disagree with the Dean on that. Berman's Center for Integrative Medicine is an embarrassment to the University, and its presence undermines the efforts of other scientist to understand and treat disease.

But hey, maybe I’m missing something. Perhaps I just have a blockage in my qi.

(For further reading, I highly recommend the excellent blog posts on the Berman et al. study by Mark Crislip, David Gorski, and Steven Novella, all at Science-Based Medicine.)

15 comments:

  1. on a related note 37% of americans believe in haunted houses:

    http://www.gallup.com/poll/17275/onethird-americans-believe-dearly-may-departed.aspx

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  2. The real shame is that there is no legitimate way to use placebo effect. In order for accupuncture(or a sugar pill) to work you have to misdirect the subject to make them believe. Something doctors should not do.
    As someone with chronic back pain, I would love it if simply being jabbed with a couple of toothpicks would make me more comfortable. I also think it would be cool if there were really werewolves. Oh, well.

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  3. You said:

    Without getting into the details (most of these studies are poorly done), it’s no surprise that sticking needles into the skin causes a physiological effect.

    Do you feel there are studies that show positive benefit to accupuncture that are well done?

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  4. Anonymous: I haven't seen a single study reporting a positive benefit for acupuncture over placebo that is well done. There are studies in low-quality journals that report some positive results, but the better studies contradict them. There are studies showing irrelevant things (as I point out in my blog) such as changes in various stress-related hormones, but these don't show any benefit for acupuncture, despite the claims of some acupuncture proponents.

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  5. Don't stress related hormones correlate with pain?

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  6. The fact remains that some patients "benefit" from the placebo effect. So I suggest in cases where competent doctors have basically no idea why a patient is suffering some pain, they can recommend a placebo treatment at a placebo clinic (obviously it would be named something to help the patient suspend disbelief). Also, we can "train" some unemployed individuals how to place toothpicks on the skin for a fee of $10/treatment (the fee may need to be increased to help the patient feel like they are actually paying for something great). Also, every placebo clinic will need a machine that goes "Ping". This benefits the patient at least psychologically, frees up doctors to actually treat patients, and provides jobs to people looking for jobs.

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  7. I thought the positive effect of acupuncture was related to the needles' ability to dilate or constrict blood vessels around the pain site (much like caffeine or painkillers, only without the long-term side effects of addiction, re-bound headaches, etc.) I don't think you need qi to explain the impact of acupuncture - perhaps qi was the mechanism used to explain the treatment to superstitious peasants and other individuals who didn't/couldn't understand the physical workings of the sub-dermal body??

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  8. It is really too bad that you remain blind to any studies that have a positive result from use of acupuncture. http://www.ncbi.nlm.nih.gov/sites/entrez/15611487

    Is only one amongst many. I agree, at this point there are not a large amount of well done studies available in the english language. If you can possibly step away from your preconceived notions of that which does not fit into your world view, you may actually remember what medicine is supposed to be about...the patient. If it is working for hundreds of thousands of people around the world, do you think that there just might be something to it beyond "magic"? Just a thought, do you also hold the belief that love is not real? I don't think you'll find a "good" study out there that meets your golden standards, so....

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  9. To The Lorax and Anonymous:
    I think placebo effect is a really interesting public health issue. It's clear and scientifically proven that placebo can be effective for a variety of conditions, but how can it be used in a medically "legitimate" way? I always wonder how many placebo "practitioners" (especially in alternative medicine and psychiatry) know that they are essentially using placebo but can't say it.

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  10. You simply don't understand placebo effect -- it's as simple as that. If you did, you would see the cognitive dissonance in your lead paragraph: While you seem to acknowledge the researchers' findings that back pain can be mitigated regardless of where needles are inserted, you pounce on that finding then quickly conclude that "acupuncture doesn't work." And you never look back.

    What REALLY doesn't work in re this kind of research and the scientific community's reaction to it is the scientific method. When it comes to recognizing, measuring and describing pain and its mitigation, the method comes up quite short. And it causes other well-meaning researchers to accuse their good colleagues of junk science.

    This research is not junk. It's interesting. It could be pathbreaking. Don't knock it until you at first recognize the limitations of our tools for measuring results when it comes to stopping pain. If anything, you should be critical of the medical community that consistently dismisses placebo effect. If placebo is "felt" by the patient, then something "real" is happening -- and that demands a better understanding.

    Even if placebo is purely psychological, it shows up in a physiological framework -- MRI scans demonstrate this. Traditional Chinese medicine likely stumbled upon this effect by accident, and in the practitioners' zeal to explain it, they came up with qi, meridians and so on. Just like us, these practitioners and scholars used the tools and methods they had available to them at the time. You should consider us just as limited when it comes to our understanding of pain.

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  11. Life force is electromagnetic energy. Pretty simple.

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  12. Anonymous,

    First, I would suggest you don't understand cultish thinking - why do you have a need to defend something science has studied, for decades, and found wanting? I would also suggest your identity may be wrapped up in it. You are certainly not approaching this as a disinterested observer. It's important to you. Why? What cultural environment are you in/a part of that makes arguing for something with little scientific basis your battle?

    This is not "interesting" - especially when you've had to deal with the harm these things cause. All "alternative medicine" comes with a belief system, and once one accepts that belief system, then the little things - like lying to your patients on a mass scale under the guise of the placebo effect - becomes O.K.. So does alienating friends and family who don't go along. So does insisting that science, which has served us so well, is somehow flawed when it comes to these practices - but no others. And why are all the major practitioners and proponents in the West known for flim-flam, while in the East, they're moving away from this sort of thing?

    This isn't a question of ourselves as "limited when it comes to our understanding of pain" but a question of ourselves as limited when it comes to critical thinking about culture. We sell homeopathy (water) as "a new way of healing" in Whole Foods when it's been around for 200 years and never healed a soul. And it's defenders are as fired up as you are. They, too, cannot let science make the judgements, but are determined to jump into the breech without asking themselves "why?"

    I have a blog where I deal with these issues, and their fallout, in my own unconventional manner. My wife killed three people utilizing these practices. I have that right.

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  13. Out of solidarity:

    http://scienceblogs.com/insolence/2010/08/quackademic_medicine_infiltrates_the_new.php

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  14. You think you know a little something about acupuncture. .. you don't. I have been practicing at the Cleveland Clinic Department of Pain Management for 6 years and would put my success rate against any pain physicians practicing anywhere - we win few, we lose a few. I do practice a unique style of physical medicine/structure function acupuncture so we may be comparing apples to oranges but when you denigrate a whole discipline based on a study of one particular protocol and your own obvious pre-identified agenda you have less credibility than that you assign to the whole acupuncture field with your contemptious pseudo argument. Likewise your argument against osteopathic manipulative therapy is also garbage. .. structure influences function. . .if you can restore structure you can often positively influence function - that's all it says and it is a powerful treatment modality. . . I would also compare our staff osteopath's success with any pain docs practicing 'conventional' medicine. AND for the record, in roughly ten years acupuncture experience treating thousands of patients I have NEVER seen a single infection from acupuncture. . whereas as a patient of conventional medicine I have received potentilly serious infections after conventional medical procedures. There is a reason why acupuncturists have low malpractice insurance fees.

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