Every so often, I mention that there was a time about 10-15 years ago when I thought that there just might be something to acupuncture. Sure, I never accepted the mystical magical mumbo jumbo ideas behind acupunctures, such as how it somehow redirects the flow of qi or that there are “meridians” along which this qi flows. After all, unlike a lot of forms of alternative medicine that were clearly quackery, acupuncture actually involved inserting needles into the body. So I thought that maybe there was something, some mechanism by which acupuncture might accomplish some health benefits.
Then I actually started delving into the scientific literature on acupuncture. It soon became apparent to me that acupuncture‘s effects are nonspecific, no greater than placebo acupuncture and that the more rigorous the clinical trial, the smaller the apparent effect of acupuncture relative to placebo, until in the best-designed studies acupuncture is no better than placebo. As I like to say, it doesn’t matter where the needles are placed. It doesn’t even matter if the needles are placed. Indeed, twirling toothpicks against the skin produces the same effect. Basically, acupuncture is nothing more than a theatrical placebo. It does not work. It took me a couple of years to come to this conclusion, but come to it I did.
Unfortunately, in the world of quackademic medicine, where quackery has infiltrated bastions of academic medicine, acupuncture is the gateway woo that leads to the harder stuff, like homeopathy (brought in by naturopaths) or “energy medicine.” Nowhere is that more apparent than at that supposed pinnacle of American academic medicine, Harvard Medical School. Unfortunately, Harvard has a thing for woo, including acupuncture. It’s even more than that, though. For example, Harvard has for at least ten years offered a course that it calls The International Structural Course for Physicians: A Palpation-Based Approach. If you’re a physician, you can get over 300 continuing medical education credits for taking the course, as well.
So maybe it shouldn’t be surprising that I came across a post on the Harvard Health Blog entitled Acupuncture for headache. It was written by Helene Langevin and Carolyn A. Bernstein. I note that I’ve written about Langevin on at least two occasions before. First, it appears that she’s moved up in the world, because the last time I took note of her she had co-authored arisibly bad study in which the authors claimed to have identified anatomic structures corresponding to actual acupuncture meridians. There are, of course, no known physiological or anatomic structures that correspond to acupuncture meridians, which brings up the question of how it was that practitioners of traditional Chinese medicine “identified” these channels in the first place. Science can’t tell the difference. Meridians don’t correspond to any nerves, and there’s no physical criteria by which meridian can be distinguished from non-meridian other than magic and fairy dust. None of this stopped Langevin from trying to use a combination of ultrasound and impedance measurements in a tour de force of what Harriet Hall so famously dubbed Tooth Fairy Science. Contrary to their conclusions, the failed to find them. I also can’t help but note that, at the time I last wrote about Langevin, she was still at the University of Vermont. Now she’s Director of the Osher Center for Integrative Medicine at Harvard Medical School and Brigham and Women’s Hospital. She’s moved up in the world.
The other co-author is Carolyn Bernstein, who happens to be a neurologist at the Osher Clinical Center, specifically a Headache Medicine Specialist.
So what do Langevin and Bernstein have to say under the imprimatur of the mighty Harvard Medical School? Nothing good, at least scientifically speaking:
It is easy to ridicule a 2000-year-old treatment that can seem closer to magic than to science. Indeed, from the 1970s to around 2005, the skeptic’s point of view was understandable, because the scientific evidence to show that acupuncture worked, and why, was weak, and clinical trials were small and of poor quality.
But things have changed since then. A lot.
Actually, no they haven’t. The vast majority of acupuncture studies remain small and of poor quality. Even larger trials tend to be of poor quality as well. None of this stops our Harvard faculty members from opining:
Thanks to the development of valid placebo controls (for example, a retractable “sham” device that looks like an acupuncture needle but does not penetrate the skin), and the publication of several large and well-designed clinical trials in the last decade, we have the start of a solid foundation for truly understanding the effectiveness of acupuncture.
I’ve written about a number of those supposedly “large and well-designed clinical trials,” and inevitably I’ve been…underwhelmed. Inevitably, they have serious methodological problems that limit their generalizability. Amusingly, at least one of the studies listed at the end of the post actually found no difference between sham acupuncture and “real” acupuncture, which is the very definition of a negative study.
Individual large-scale clinical studies have consistently demonstrated that acupuncture provided better pain relief compared with usual care. However, most studies also showed little difference between real and sham (fake) acupuncture. In order to address this concern, a 2012 meta-analysis combined data from roughly 18,000 individual patients in 23 high-quality randomized controlled trials of acupuncture for common pain conditions. This analysis conclusively demonstrated that acupuncture is superior to sham for low back pain, headache, and osteoarthritis, and improvements seen were similar to that of other widely used non-opiate pain relievers.
Acupuncturists do so love the meta-analysis by Andrew Vickers, don’t they? Again, I’ve discussed this one in nauseating detail. For instance, in 2012, I asked: Can we finally just say that acupuncture is nothing more than an elaborate placebo? Can we? (It wasn’t the first time I asked that question, which in fact echoes a later statement by David Colquhoun and Steve Novella declaring acupuncture to be nothing more than a theatrical placebo.) Amusingly, Vickers did not react well to criticism of his 2012 meta-analysis by myself, Steve Novella, and Mark Crislip. Yes, this is one of the most widely cited acupuncture studies used to argue that acupuncture works, but it actually doesn’t show anything of the sort. At best, it shows that if there is a difference in pain perception in patients due to acupuncture it’s statistically significant but clinically insignificant.
Langevin and Bernstein make some extravagant claims as well. For example:
Meanwhile, basic science studies of acupuncture involving animals and humans have shown other potential benefits, from lowering blood pressure to long-lasting improvements in brain function. More broadly, acupuncture research has resulted in a number of insights and advances in biomedicine, with applications beyond the field of acupuncture itself.
This is the sort of expansive statement that cries out for citations to back it up. I perused the list of references, and I couldn’t see what the authors are talking about. Of course, the evidence that could be marshaled in support of each of those statements consists of studies of the usual level of quality used to support the efficacy of acupuncture, namely low quality studies, often not properly controlled. Personally, I also wonder what “insights and advances” in biomedicine”” Langevin and Bernstein mean that go “beyond the field of acupuncture itself.” Certainly, none of their references support this claim. If they mean the study in which the efficacy of acupuncture is claimed to be due to the release of adenosine. Whether they meant this study or not, I cite it because it’s an example of a study that was vastly overinterpreted by acupuncture advocates and not actually relevant to whether acupuncture works or not. It did, however, lead to some major rebranding of a non-acupuncture modality as acupuncture. That reminds me. The “adenosine/acupuncture” studies remind me a lot of the pointless (if you’ll excuse the term) acupuncture studies done by Langevin.
Which is funny, given this passage:
We understand why there may be continued skepticism about acupuncture. There has been ambiguity in the language acupuncture researchers employ to describe acupuncture treatments, and confusion surrounding the ancient concept of acupuncture points and meridians, which is central to the practice of acupuncture. Indeed, the question of whether acupuncture points actually “exist” has been largely avoided by the acupuncture research community, even though acupuncture point terminology continues to be used in research studies. So, it is fair to say that acupuncture researchers have contributed to doubts about acupuncture, and a concerted effort is needed to resolve this issue. Nevertheless, the practice of acupuncture has emerged as an important nondrug option that can help chronic pain patients avoid the use of potentially harmful medications, especially opiates with their serious risk of substance use disorder.
Ah, yes, no pro-acupuncture article can conclude without an attempt to claim that acupuncture is a potential solution to the opioid crisis as a “nonpharmacological treatment for pain.” It’s a central talking point and overall message of proponents of “integrative medicine” (i.e., the “integration” of quackery into medicine), such as the National Center for Complementary and Integrative Health (NCCIH), major medical journals like JAMA, major medical societies like the American College of Physicians, and advocates trying to get Medicaid to fund acupuncture. I also can’t help but point out yet again that Langevin herself has contributed to the “confusion” surrounding the question of whether acupuncture points actually “exist.” Actually, there is no confusion among anatomists, neuroscientists, and other medical scientists who are not acupuncture advocates. Meridians do not exist as any sort of distinct anatomic structure, Langevin’s tortured efforts to demonstrate otherwise notwithstanding.
As for a “concerted effort” being needed to “resolve this issue,” that’s utter nonsense. The issue was resolved long ago by anatomists and neuroscientists. Only acupuncture advocates try to torture science, evidence, and logic to make it seem as though there is doubt about that an that acupuncture points might really exist. Let’s just put it this way. There was a good reason why, long ago, I mocked Georgetown University long ago and more recently for having “integrated” acupuncture teaching into first year anatomy class in medical school.
Finally, the authors seem so very, very disturbed that critics criticize acupuncture as pseudoscientific:
A post on acupuncture last year dismissed acupuncture as a costly, ineffective, and dangerous treatment for headache. This prompted us to point out the need for a measured and balanced view of the existing evidence, particularly in comparison to other treatments. Although the responses that followed the article overwhelmingly supported acupuncture, it nevertheless remains a concern that this practice attracts this kind of attack. Acupuncture practitioners and researchers must take responsibility for addressing deficiencies in acupuncture’s knowledge base and clarifying its terminology.
That said, we need to recognize that acupuncture can be part of the solution to the immense problem of chronic pain and opiate addiction that is gripping our society. That this solution comes from an ancient practice with a theoretical foundation incompletely understood by modern science should make it even more interesting and worthy of our attention. Clinicians owe it to their patients to learn about alternative, nondrug treatments and to answer patients’ questions and concerns knowledgeably and respectfully.
Respect is earned. For medical therapy, it is earned by evidence and science supporting the efficacy of that therapy, as well as effect size. More evidence and compelling science = more respect. Greater effect size = more respect. Acupuncture fails on both counts. It has no compelling evidence supporting the contention that it is anything more than a theatrical placebo, and the best evidence that its advocates can present, even if taken at face value and its extreme weakness ignored, supports no more than at best a clinically insignificant effect size.
As for acupuncture being an “ancient practice with a theoretical foundation incompletely understood by modern science,” I laughed out loud when I read that line. Acupuncture is a prescientific, vitalistic practice based on ancient Chinese religion that started out far more akin to sort of bloodletting that “Western” physicians did hundreds of years ago than it is to anything resembling modern science. That’s it’s “theoretical foundation.” Everything else (such as adenosine, “counterirritation,” etc.) are tortured rationalizations grafted on to those ancient ideas by scientists desperate for a scientific explanation and rationale for how “acupuncture works.” Too bad they seldom seem to ask the real question: Does acupuncture work? They simply assume that it does.
The hilarious thing about this blog post is that the post by the acupuncture critic that prompted it is far more on point than Langevin and Bernstein’s rebuttal. The not-so-hilarious thing about Langevin and Bernstein’s post is that it’s yet another indication how quackademic medicine has so completely triumphed in a bastion of medical science as prestigious as Harvard.