Alternative medicine as a placebo

I recently wrote a post about the decision by NICE to no longer recommend acupuncture for lower back pain. This decision was made because, like most alternative medicine, acupuncture hasn’t been shown to work any better than a placebo. However, plenty of people use and get benefit from such treatments. This raises an interesting question: is there a place for complementary and alternative medicine (as a placebo) in the clinic?The ethics of prescribing placebos is a complicated topic. People are perfectly entitled to use alternative medicine, and if they get a benefit, that’s obviously good. However, whether a doctor should prescribe alternative medicine is a different matter.As I have previously written, most complementary and alternative medicine works purely on the placebo effect. People argue that alternative medicine should be allowed to be prescribed, because if the placebo effect helps someone, then that justifies its use. Indeed, here in Glasgow we have an NHS funded “homeopathic hospital”, and if it helps people, why should we stop that?Unfortunately it’s not that simple. If a doctor prescribes such a therapy, it has the effect of offering a medical credibility to the therapy that doesn’t work. This may not sound like a big problem, but it is. There are many examples of people eschewing mainstream medicine for “natural” alternatives and herbal remedies.A court in Canada, for example, recently convicted the parents of a child who died from meningitis after they consulted a naturopath rather than a medical professional. The naturopath recommended the parents give ecinachia to their dying child. This isn’t an isolated case; it’s worth visiting the What’s the Harm website to see the toll that belief in pseudoscience can have.The reality is that if a doctor prescribes acupuncture for pain, then a patient is more likely to believe the plethora of false claims that an acupuncturist may make (including it being effective against diabetes, heart attacks, cancer and even ebola). This in turn increases the risk of patients postponing or declining evidence-based conventional treatment when it is needed. It was recently shown that women who were using certain alternative therapies were less likely to start chemo for their breast cancer. Regardless of whether someone benefits from the placebo effect given by an alternative therapy, it is simply not ethical to legitimise it as a practice. Furthermore, it is perfectly possible to give a placebo that does not come with the added nonsense, which brings me on to my next point.In 2008, the American Federal Trade Commission made a ruling on the use of the Q-Ray Ionised Bracelet in medicine. The makers argued that they could claim it was a cure for chronic pain because, like acupuncture and other alternative medicine, it exhibited the placebo effect. In his ruling on the case, the judge said the following:

“Like a sugar pill, it alleviates symptoms even though there is no apparent medical reason. Since the placebo effect can be obtained from sugar pills, charging $200 for a device that is represented as a miracle cure but works no better than a dummy pill is a form of fraud.”

When we can get the same or similar effects from a far cheaper placebo, then a doctor prescribing alternative medicine is ripping off their patient or the NHS. With already stretched resources, it is scandalous that the NHS pays £1.33 million per year to the Glasgow Homeopathic Hospital. People spend a huge amount of money on alternative medicine (it’s a $34 billion industry in the US), a product that doesn’t work, and is also completely unregulated.The unregulated nature of the industry is something that people are generally unaware of. Numerous studies have shown that alternative remedies regularly contain contaminants like toxic metals, pharmaceuticals, insects, rodents, parasites, fungi, pesticides and other fillers. These contaminants have led to serious illness is many cases, and several deaths. Prof. Edzard Ernst (former Chair in Complementary Medicine at the University of Exeter) has written extensively about this topic and is a good place to look for more information.The placebo effect has a significant role to play in health care. It can undoubtedly improve subjective symptoms in a number of contexts. However, while any effect alternative medicine has can be explained by placebo, the industry claims that it does much more than that. Couple this with the unregulated nature of the products and the expense involved, and it is clear that alternative medicine should never be given legitimacy by the mainstream medical community. I’ll leave you with this quote from Tim Minchin: 

"By definition", I begin"Alternative Medicine", I continue"Has either not been proved to work,Or been proved not to work.Do you know what they call "alternative medicine"That's been proved to work?Medicine."

https://www.youtube.com/watch?v=HhGuXCuDb1U

Acupuncture no longer recommended for back pain

NICE (the organisation that provides guidance to doctors in the UK) recently updated their recommendations regarding lower back pain. In the updated guidance, they say that exercise, in all its forms (for example, stretching, strengthening, aerobic or yoga), is the most important step in managing back pain. Previously, NICE also recommended acupuncture or massage, but this has now been altered. Massage can still be used alongside exercise, but the guidelines no longer recommend acupuncture, as "evidence shows it is not better than sham treatment".This is not entirely surprising as, despite widespread acceptance of acupuncture, the evidence that it works for any illness or disability is very scant (as I have described in a previous post). Most studies are poorly carried out, and many show no difference between it and sham acupuncture.Unfortunately, the authors of these studies often conclude that both acupuncture and sham acupuncture work, rather than the actual conclusion (that acupuncture doesn't work). If a medicine works no better than a sham medicine (a sugar pill for example), we cannot conclude that both the medicine and the sugar pill work.For those suffering from back pain, the new recommendations also encourages people to continue with normal activities as far as possible, and recommends that non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen or aspirin should be tried. Unfortunately, at present there is no evidence to back up other interventions.A recent study found that back pain caused more disability than any other condition, and is also responsible for 37% of all chronic pain in men and 44% in women. While it is understandable that people seek relief from their symptoms, it is obvious that the NHS can't fund a treatment that does not work.

Have we explained how acupuncture works?

Acupuncture is a topic that divides people. It is seen by some as a little understood branch of medicine, by others simply as pseudoscience. The theory states that inserting needles at specific points can have effects on almost every ailment, from chronic pain and allergies to irritable bowel syndrome and even stroke. At present, however, there is little reliable evidence that acupuncture works any more than placebo, which makes this article from The Guardian quite unexpected:

Rats help scientists get closer to solving the mystery of acupunctureThe Guardian - 21/07/2015

The title is surprising because this was not a report on acupuncture. The scientists applied an electric current through the acupuncture needles. This technique is called transdermal electrical stimulation and is already used in the clinic to treat chronic pain. The authors, however, call it “electroacupuncture“, and equate it to acupuncture. They are not the same thing, and the conclusions are hence not about acupuncture at all.Scientifically there are many other problems with this study. This was a tiny experiment, with only 7 animals being tested with the “electroacupuncture”. It was not blinded, meaning that the experimenters knew what treatment they were giving to each animal. You may not think that this is an important issue, but consider this: studies on acupuncture in the West yield very mixed results, leading us to believe that the effects are either tiny or non-existent. In China, Japan and Taiwan, where there is a culture of belief, almost every single study shows a positive result. The belief of the experimenter can drastically influence the result of an experiment. Blinding is essential in such studies to overcome this.It is also worth drawing attention to the controls used in this study. The experimenters compare “electroacupuncture” to two controls: sham-acupuncture and no acupuncture. Sham-acupuncture is specifically in place to test for the presence of the placebo effect. Depending on the study, sham-acupuncture can be one of a few things, from inserting the needle at a random point in the body to the use of needles that retract into the sheath, so there is no penetration of the skin at all. In this study, the authors used the insertion of their electric needle at a non-acupuncture point as the sham.Tellingly, the authors did not report any difference between sham-acupuncture and acupuncture. The fact that this isn’t reported, and a look at the data presented in the paper, suggests that there is no difference between their “electroacupuncture” and sham. They only report that “electroacupuncture” seems to be slightly better than the no treatment control. So not only their results are unspectacular, but can be entirely explained by placebo effects. It is worth pointing out that the placebo effect can be extremely powerful, and people can see vast improvements when using any therapy that may not be due to the therapy themselves, but down to the placebo effect. This is why we control for it in trials.This control issue with the study is one that is common with other acupuncture research. It is regular these kinds of studies to see no difference between acupuncture and sham-acupuncture, and rather than conclude that acupuncture doesn’t work, they conclude that both acupuncture and sham-acupuncture work, and this is just not true! If a drug had the same level of effect as a sugar pill, we wouldn’t conclude that both are working. Unfortunately, it is rare for studies into pseudoscience to hold themselves to the same standards.Put simply, this is a badly designed study, from which the authors conclude that acupuncture works, seemingly without actually looking at acupuncture at all. At present, we cannot even say that there is a “mystery of acupuncture”, as described in the headline of this article. There is no mechanism in science or medicine through which sticking needles into particular points around the body can have very specific effects on other parts, so to claim acupuncture works would require convincing evidence (extraordinary claims require extraordinary evidence). This is certainly not that.