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

Over the last several years, the Veterans Health Administration has been increasing the amount of quackery being offered in VA hospitals and clinics. This time around, it’s auricular acupuncture.

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.

By Orac

Orac is the nom de blog of a humble surgeon/scientist who has an ego just big enough to delude himself that someone, somewhere might actually give a rodent's posterior about his copious verbal meanderings, but just barely small enough to admit to himself that few probably will. That surgeon is otherwise known as David Gorski.

That this particular surgeon has chosen his nom de blog based on a rather cranky and arrogant computer shaped like a clear box of blinking lights that he originally encountered when he became a fan of a 35 year old British SF television show whose special effects were renowned for their BBC/Doctor Who-style low budget look, but whose stories nonetheless resulted in some of the best, most innovative science fiction ever televised, should tell you nearly all that you need to know about Orac. (That, and the length of the preceding sentence.)

DISCLAIMER:: The various written meanderings here are the opinions of Orac and Orac alone, written on his own time. They should never be construed as representing the opinions of any other person or entity, especially Orac's cancer center, department of surgery, medical school, or university. Also note that Orac is nonpartisan; he is more than willing to criticize the statements of anyone, regardless of of political leanings, if that anyone advocates pseudoscience or quackery. Finally, medical commentary is not to be construed in any way as medical advice.

To contact Orac: [email protected]

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

Why not just get a plastic model of an ear and stick needles in it? Thousands of years of voodoo dolls have proven that the approach works.

Wouldn’t it be easier, cheaper, and more honest, to simply add a spa unit to VA facilities to offer a great feel good experience to depressed and anxious vets? The spa should probably have a pot bar as well.

The spa idea probably would do some vets a lot of good. Getting a needle stuck in your ear might increase stress levels as you wonder if your doctor has gone stark raving mad.

It didn’t take the pain away, but it makes me feel good.

So the acupuncture didn’t do what it was claimed to do, but had other unspecified (and likely unquantifiable) “benefits”. Yes, I would call that an epic fail. In any category but medical woo, this program would be an obvious candidate for the chopping block–I have seen programs with quantifiable positive effects terminated on flimsier justifications. I would be fine with spending money on something that actually works, and I can understand the reluctance to prescribe opioids because the fear of getting patients addicted to pain pills is rational, but acupuncture is not a solution to these problems.

Five needles a day keeps the doctor away
While quacks gather ’round and play.
..But some veterans ain’t dumb,
..They say, stick it in your…plum,
And get by on one opioid a day.

Hmmm. I’m seeing quite a bit of irony in recently-popular CAM modalities that tell users to “stick it in your ear” and “shove it up your ass.”

I’ve got many, many snarky questions:
What if you had your ear blown off by and IED and then sewn back on, does it still map the same? What if they couldn’t put your ear back, do you just use one ear for both sides of the body?
What if you have piercings? Shouldn’t my friend with the dozen ear piercings be totally free of pain and the epitome of health?

On a more serious front: do they ever look at these vet’s homes? Are they accessible? Are they easily accessible? Do they have a comfortable and supportive chair to sit in? Is their mattress so old it is exacerbating their back problems? Does the vet with knee problems live in a 3rd floor walk-up? How about looking at the physical environment before promoting nonsense?

@ JustaTech:

I can attest that ear piercings don’t do anything for pain: in the 1990’s I got 3 extra piercings in my left ear ( that I don’t use any more) . I had a series of leg injuries in my left leg and doubt that there was any pain relief.

HOWEVER I DO think that earrings might serve as a form of pain relief if they are expensive enough.Magic!
I’m not entirely joking.

I can just see on the battlefield a wounded soldier and no needles to relieve the pain and the medic just says just shoot him in the ear. When the pains continues, shot him in the other ear.

As I told a doctor once you can do it only if I get to do it to you first.

Orac writes,

I’ll conclude by repeating yet again that our veterans deserve the very best science-based health care that the nation can offer them.

MJD says,

Indeed, my brother is a disabled veteran.

A decade, or two, ago he tried to get assistance based on loss of hearing (explosion) and other body damage that required surgery during his service.

Back then, the Veterans Administration (VA) doctor denied his claim but provided $20 with the request/order that it can’t be spent on booze.

The psychological scar from this rejection still infuriates him today.

Luckily, this brave soldier remained persistent and received help from another VA doctor who showed tremendous compassion for his situation.

It’s clear that VA doctors may have conflicting opinions, therefore, allow our honored veterans multiple treatment options that provide them the freedom to choose.

Where should I stick a needle in my ear to ease the nerve pain caused by my lumbar stenosis? I promise I’ll sterilize the needles and everything. Will it still work even though I’m not a veteran?

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