More “auricular” acupuncture: Our veterans deserve science-based medicine, not quackery

It’s a new year, but sadly the same old nonsense is continuing. I know I shouldn’t be surprised. After all, years are just arbitrary periods of time used to keep track of it, but culturally we humans are wired to think that there’s something special about a new year, that decades have distinct characters, when in reality time just blurs from one day to another, one month to another, one year to another. This time around, the nonsense is something that’s been going on for several years, and it’s about our veterans. I always like to say that the men and women who have served our country in the armed services deserve the very best science-based care, particularly if they’ve been wounded in combat or injured while in the service. Unfortunately, these days, the Veterans Health Administration, which runs the Veterans Administration (VA) medical centers, doesn’t seem to agree; that is, if this article that appeared in the Baltimore Sun is any indication:

Seeking ways to curb the use of opioid painkillers, doctors at Baltimore’s VA Medical Center started offering a version of acupuncture to treat some veterans’ chronic pain.

Two years later, the U.S. Department of Veterans Affairs has embraced the therapy based on the traditional Chinese practice of inserting needles into the body to treat maladies. The VA is using acupuncture at clinics across the country.

There is little research to support the effectiveness of acupuncture, but the federal agency now plans to study its use.

The willingness to try alternative methods of treating pain reflects the VA’s pressing need to reduce the use of addictive opioids for the thousands of men and women who leave the military with chronic pain or develop it as civilians.

There they go again! I’ve written about this rationale many times. Basically, promoters of pseudoscience seeking to “integrate” quackery with medicine in the form of “complementary and alternative medicine” (CAM) and “integrative medicine” have co-opted nonpharmacologic treatments for chronic pain as somehow being in their bailiwick and used the opioid crisis as an excuse to promote unproven, mystical, and/or pseudoscientific treatments like acupuncture as one of the answers to the opioid crisis. Indeed, the National Center for Complementary and Integrative Health (NCCIH) has recently basically based its existence on CAM being a major component of the answer to opioid addiction, and even the FDA seems to be weakening its stance. Meanwhile, acupuncture advocates are advancing on multiple fronts, recently even getting the state of Ohio’s Medicaid program to pay for acupuncture services.

If you watch the video that accompanies the story (sorry, it’s not embeddable), you will find seriously credulous reporting about so-called “battlefield acupuncture.” Of course, I’ve also written multiple times about battlefield acupuncture going back to 2008 and continuing to less than a year ago. It’s a modality championed by Col. (Dr.) Richard Niemtzow, a radiation oncologist and Air Force physician turned woo-meister-in-chief and number one advocate of acupuncture use in the military, who “pioneered” the use of auricular acupuncture in military hospitals based on basically nonexistent evidence, even getting the Army to train its Rangers in the technique. Auricular acupuncture is even more risible than regular acupuncture in that it posits the existence of homunculi on the ears that correspond to different organs and body parts. Stick the needle in the spot on the ear that “maps” to your arm, for instance, is supposed to treat conditions affecting that arm. Acupuncturists who believe in auricular acupuncture can take it to ridiculous extremes, too. Indeed, in August there was a paper published seeking to standardize the nomenclature for auricular acupuncture, taking it to a truly silly level of detail. None of this stops a Dr. Aarti Kapoor, a doctor at the Baltimore VA Medical Center, from being featured in the video segment mentioned above and pontificating about how, because only the ear is exposed, auricular acupuncture is “simple an easy to do on the battlefield” and how it works 80% of the time to relieve pain. She also touts it as primary care for veterans and cites dubious studies on acupuncture.

Not surprisingly, the addition of acupuncture to the treatment armamentarium used by VA doctors is but a part of a greater initiative:

It also represents an effort across the VA health care system to focus more broadly on “wellness” and what the department calls “whole health,” with doctors and patients developing health goals such as regaining the ability to play a sport rather than simply treating one disease at a time.

For a large proportion of veterans living with chronic pain, plans often include weight loss, exercise and dietary improvements and other non-drug therapies such as massage, yoga and mindfulness training in conjunction with or instead of traditional medicine. The acupuncture treatment, piloted in Baltimore and since taken up by two dozen other VA centers, is part of that approach.

This is, of course, not the first time I’ve noticed that the VA has adopted the language of CAM, including justifying the use of quackery based on wanting to be “wholistic,” to embrace “wellness,” and to “take care of the whole patient.” There has been a concerted effort, for instance, to insinuate naturopaths into the VA, letting the VA system pay them for their services, but that’s not all. Dr. Tracy Gaudet, director of the VHA’s Office of Patient Centered Care and Cultural Transformation, has been actively promoting naturopathy and integrative medicine in the VA ever since she left her job as the director of Duke Integrative medicine, a “pioneer” institution adopting quackademic medicine, to take her current job at the VA. That, of course, includes promoting programs like this one, to integrate acupuncture as a treatment for chronic pain. And how does it work?

Not so well, actually. Meet John DeLost, who has chronic knee pain after having injured a knee while stationed in Alaska with the Army in the 1970s:

After knee surgery, the 68-year-old couldn’t walk well and opioid painkillers were no longer helping. Ice, massage, and a big weight loss were providing only some relief. The medical marijuana he wanted to try was off limits to the VA because cannabis remains illegal at the federal level.

A recent session of acupuncture gave him little relief from pain but made him feel better in other ways.

“I feel a little more energy; I can breathe better,” said DeLost, after a Veterans Affairs doctor put five tiny needles into each of his ears. “It didn’t take the pain away, but it makes me feel good.”

DeLost said he’s still not sure how or why it works — a sentiment shared by many medical experts.

So let me get this straight. The acupuncture didn’t relieve his pain, but just sort of made him “feel better”? That’s not even a good placebo!

Naturally, the article trots out Andrew Vickers, who published what is probably the meta-analysis of acupuncture most widely cited by acupuncture advocates. It’s a meta-analysis that claims to show evidence for real effects from acupuncture but in reality shows little evidence of anything of the sort, and I note that Andrew Vickers does not take criticism particularly well. The author also cites the NCCIH review from last year that found some benefit due to acupuncture. I beg to differ on that conclusion—rather strongly. Cleverly, Vickers co-opts an argument from the point of view of the patient:

“Who defines a little or a lot and what’s meaningful to patients?” said Vickers, an attending research methodologist at Memorial Sloan Kettering Cancer Center in New York. “Whether it was worth having acupuncture or not was a subjective opinion.”

Vickers said if many veterans believe they get even some relief from acupuncture, and the cost and risk remain low, then it may be reasonable to offer it, though he said the practice should have standards and continue to be studied.

This is true for treatments with an evidence base that shows that they offer small improvements to patients that are actually real and supported by clinical trials. Such a perspective doesn’t apply so much to treatments like acupuncture, which is just a theatrical placebo. Patients, of course, can pursue any sort of quackery they desire. However, as physicians we are obligated to offer treatments with sound scientific evidence for efficacy. Acupuncture doesn’t qualify.

Worse, the VA is spending a fair amount of money on this, and is poised to spend more, for instance on “battlefield” or auricular acupuncture:

A training program was developed about two years ago at the Defense and Veterans Affairs departments. The VA couldn’t say how much it has spent on training and treatment, but it and the Department of Defense plan to spend $81 million over six years on 12 research projects to address pain and other conditions using non-drug approaches, including battlefield acupuncture.

In the article, Steve Salzberg quite correctly points out that the form of auricular acupuncture touted by Col. Dr. Niemtzow and being adopted by the VA was “made up out of whole cloth” in 2001 and not yet put under any significant review. He’s absolutely correct. The evidence base for battlefield acupuncture is weak, even by acupuncture standards.

So what reasons is the VA giving to embrace acupuncture, besides to combat the opioid epidemic? Listen to Dr. Carol Bowman, medical director of patient and family-centered care for the VA Maryland Health Care System argue against Steve Salzberg’s criticisms of acupuncture in general and auricular acupuncture in particular:

The VA’s Bowman countered that if patients believe that it’s helping their pain — and the bulk of her patients say that it is — then it is. And since pain is related to anxiety and depression, common among veterans, a perception that acupuncture helps also can improve mood and outcomes, she said.

So why use acupuncture? If you’re going to go full bore placebo medicine, why not go all in and just use something like homeopathy, which is basically water? Of course, I shouldn’t give Dr. Bowman and Dr. Gaudet any ideas. After all, if Dr. Gaudet gets her way, it probably won’t be long before there are naturopaths practicing in every VA hospital and clinic in the country.

I’ll conclude by repeating yet again that our veterans deserve the very best science-based health care that the nation can offer them. Increasingly, what the VA is offering them, particularly those unfortunate enough to be suffering from chronic pain from service-related conditions is the opposite of that.