The US will try treating opioid addiction with fake medicine

If you can't afford to offer real medical care, why not offer fake medicine? The U.S. Medicare system is about to give this strategy a try, for treating back pain.

Last week, Medicare announced that it wants to start paying for studies of acupuncture as a treatment for low back pain, as reported by the Washington Post and Stat. The government's reason, according to Secretary of Health and Human Services Alex Azar, was that we need this option to help solve opioid addiction:
“Defeating our country’s epidemic of opioid addiction requires identifying all possible ways to treat the very real problem of chronic pain, and this proposal would provide patients with new options while expanding our scientific understanding of alternative approaches to pain.”
If you break down HHS Secretary Azar's statement, it's mostly correct. Yes, treating opioid addition should explore all methods for treating chronic pain. And yes, this program will provide "new" options, even though the option in question is nonsense.

But (3) no, studying acupuncture will not expand our scientific understanding of "alternative approaches" to pain. Why not? Because thousands of studies have already been done, and the verdict was in, long ago, that acupuncture is nothing more than an elaborate placebo.

The problem is, acupuncture proponents never give up. Every time a study shows that acupuncture fails (and this has happened, repeatedly), they claim it wasn't done properly or make another excuse. I've even seen proponents argue that studies in which acupuncture failed were in fact successes, because acupuncture and placebo treatments both outperformed the "no treatment" option.

(Aside: we use placebo treatments because we've known for decades that any treatment, even a sugar pill, may show a benefit as compared to no treatment at all. Acupuncture research has created placebos by using fake needles that don't actually pierce the skin, or by placing needles in random places rather than the so-called acupuncture points. Scientifically speaking, if a treatment doesn't outperform a placebo, then the treatment is a failure.)

To make matters worse, the new HHS program will fund "pragmatic" clinical trials rather than the usual, gold-standard randomized trials (RCTs). Without going into details, let's just say that pragmatic trials are much less well-controlled than RCTs, allowing more room for mistakes and misinterpretation. This is a bad idea even when the intervention being studied is legitimate. It's an even worse idea here, where trials have shown, over and over, that acupuncture doesn't work.

Secretary Azar might be confused because the acupuncture industry has managed to get hundreds of studies published, many of them positive–but most of them are poorly designed, and who has time to read all that bad science? (The rare well-designed studies always show that acupuncture doesn't work.) Acupuncturists have even created pseudoscientific journals devoted entirely to acupuncture, as I wrote about in 2017. Some of these journals are published by respected scientific publishers, but they are still little more than fake journals.

Not surprisingly, with entire journals trying to fill each issue with acupuncture articles, last week's Medicare announcement noted that
"the agency [CMS] recognizes that the evidence base for acupuncture has grown in recent years". 
No, it hasn't. What has grown is the number of articles. Adding more garbage to a pile doesn't make it smell better.

For those who aren't familiar with the claims of acupuncture, let's do a very quick summary: acupuncturists stick needles in a person's body at specific points in order to manipulate a mystical life force that they call "qi" (proounced "chee"). This idea is "a pre-scientific superstition" that has no basis in medicine, physiology or biology, and has never had any good scientific evidence to support it.  Acupuncturists don't even agree on where the acupuncture points are, which should make it impossible to do a scientific study. It's not at all surprising that acupuncture doesn't work; indeed, if it did work, modern medicine would have to seriously examine what mechanism could possibly explain it.

But wait, argue proponents, what about all the wise traditional doctors in China who developed acupuncture over thousands of years? Well, it turns out that acupuncture wasn't popular in China until the mid-20th century, when Chairman Mao pulled a fast one on his population because he couldn't supply enough real medical care. Mao didn't use acupuncture himself and apparently didn't believe in it. I highly recommend this expose of Mao's scam, by Alan Levinovitz in Slate.

So rather than spend millions of dollars on yet another study of acupuncture for pain, I have a better suggestion for HHS: invest the funds in basic biomedical research, which has had a flat budget for more than a decade now. As long as it goes through proper peer review, almost any research will be far better than wasting the money on acupuncture.

Now, I'm not naive enough to think that Medicare will take my advice, but I can tell them right now what their new "pragmatic" trials will reveal. Acupuncturists will happily take the money, treat people suffering from back pain, and report that some of them experienced reductions in pain. Some of the patients will invariably agree, because back pain comes and goes, and it's hard to know why it went away.

Then the acupuncturists will say, "look, it works! Now please cover acupuncture for all Medicare patients." Then we'll spend more tax dollars on pseudoscience, and patients will be in just as much pain as ever. If Medicare falls for this (and I fear they will), then Chairman Mao will have fooled the U.S. government, just as he fooled many of his own people half a century ago.

The loneliest word, and the extinction crisis

We're in the midst of an extinction crisis. Just two months ago, an international committee known as IPBES released a report, compiled over 3 years by 145 experts from 50 countries, that said 1,000,000 plant and animal species are threatened with extinction, many within the next few decades.

Martha, the very last passenger
pigeon, shown when she was
still alive.
Before getting to that report, I want to introduce a word that I only just learned: endling. An endling (the word was coined in 1996) is the last surviving member of a species. One example was Martha, the very last passenger pigeon, who died in the Cinncinnati Zoo in 1914. Passenger pigeons numbered in the billions in the 19th century, but humans wiped them out.

In 2012 we lost another endling, Lonesome George–the very last Pinto Island tortoise from the Galapagos Islands–who died at around age 100.

If you want to see a particularly poignant example of an endling, watch this rare and heartbreaking video of Benjamin, the very last Tasmanian tiger (or thylacine), pacing around his cramped enclosure in Hobart, Tasmania. This film from 1933 is the last known motion picture of a living thylacine. Benjamin died in 1936.
Two Tasmanian tigers in the Washington, D.C. zoo, in a photo
taken around 1904. Photo credit: Baker; E.J. Keller. from the
Smithsonian Institution archives

We have records of other endlings too: the last Caspian tiger was killed in the 1950s in Uzbekistan, and the last great auks were killed for specimen collectors in 1844.

Unfortunately, we're likely to see more and more endlings in the years to come. The causes of extinction are varied, and many of them are related to human activities. The IPBES ranked the culprits, in descending order, as:

  1. changes in land and sea use,
  2. direct exploitation of organisms,
  3. climate change,
  4. pollution, and
  5. invasive alien species.

In response to the IPBES report, the House of Representatives held a hearing in May to discuss the findings. Republicans on the committee took the opportunity to display a new form of denialism: extinction denialism. As reported in The Guardian, Representatives Tom McClintock and Rob Bishop used their time to attack the reputations of the report's authors, rather than addressing the very serious consequences of large-scale extinction. They called two climate-change deniers as witnesses, who also used their time to attack the authors.

This is a classic strategy used by deniers: attack the messenger, rather than dealing with the substance of the report. Let's consider just a few of the report's main findings (see much more here):

  • Across the planet, 75% of the land and about 66% of the marine environments have been significantly altered by human actions.
  • Up to $577 billion in annual global crops are at risk from pollinator loss (bees and other insects)
  • In 2015, 33% of marine fish stocks were being harvested at unsustainable levels; 60% were maximally sustainably fished.
  • Plastic pollution has increased tenfold since 1980, 300-400 million tons of heavy metals, solvents, toxic sludge and other wastes from industrial facilities are dumped annually into the world’s waters, and fertilizers entering coastal ecosystems have produced more than 400 ocean ‘dead zones’, covering a combined area greater than that of the United Kingdom.

The report is a call to action. It explains that transformative change is needed to protect and restore nature, and collective action is needed to overcome special interests such as the fossil fuel industry, which donates heavily to politicians. The Congressional hearing was a vivid demonstration of how effective the anti-environmental lobbyists have been.

Endling is the saddest word in any language. If we humans continue to treat nature as we've done in the past, we're going to see many more videos like the one of Benjamin, the last Tasmanian tiger. Let's hope we can do better.