Trick or Treatment (13 page)

Conclusions

The history of acupuncture research has followed a tortuous path over the last three decades, and more research papers will be published in the future, particularly making use of the relatively new telescopic sham needles and with a fuller evaluation of the German mega-trials. However, the research is already fitting together well, with a high level of consistency and agreement. Hence, it seems likely that our current understanding of acupuncture is fairly close to the truth, and we will conclude this chapter with a summary of what we know from the mass of research. The four key outcomes are as follows:

1. The traditional principles of acupuncture are deeply flawed, as there is no evidence at all to demonstrate the existence of Ch’i or meridians.
   
 

2. Over the last three decades, a huge number of clinical trials have tested whether or not acupuncture is effective for treating a variety of disorders. Some of these trials have implied that acupuncture is effective. Unfortunately, most of them have been without adequate placebo control groups and of poor quality – the majority of positive trials are therefore unreliable.
   
 

3. By focusing on the increasing number of high-quality research papers, reliable conclusions from systematic reviews make it clear that acupuncture does not work for a whole range of conditions, except as a placebo. Hence, if you see acupuncture being advertised by a clinic, then you can assume that it does not really work, except possibly in the treatment of some types of pain and nausea.
   
 

4. There are some high-quality trials that support the use of acupuncture for some types of pain and nausea, but there are also high-quality trials that contradict this conclusion. In short, the evidence is neither consistent nor convincing – it is borderline.
   
 

These four points also apply to variations of acupuncture, such as acupressure (needles are replaced by pressure applied by fingers or sticks), moxibustion (ground mugwort herb burns above the skin and heats acupuncture points), and forms of acupuncture involving electricity, laser light or sound vibrations. These therapies are based on the same core principles, and it is simply a question of whether the acupuncture points are pricked, pressurized, heated, electrified, illuminated or oscillated. These more exotic forms of acupuncture have been less rigorously tested than conventional acupuncture, but the overall conclusions are similarly disappointing.

In summary, if acupuncture were to be considered in the same way that a new conventional painkilling drug might be tested, then it would have failed to prove itself and would not be allowed into the health market. Nevertheless, acupuncture has grown to become a multi-billion-pound worldwide business that exists largely outside mainstream medicine. Acupuncturists would argue that this industry is legitimate, because there is some evidence that acupuncture works. Critics, on the other hand, would point out that the majority of acupuncturists treat disorders for which there is no respectable evidence whatsoever. And, even in the case of treating pain and nausea, critics would argue that the benefits of acupuncture (if they exist at all) must be relatively small – otherwise these benefits would already have been demonstrated categorically in clinical trials. Moreover, there are conventional painkilling drugs that can achieve levels of pain relief with reasonable reliability, which are vastly cheaper than acupuncture sessions. After all, an acupuncture session costs at least £25 and a full course may run to dozens of sessions.

When medical researchers argue that the evidence seems largely to disprove the benefits of acupuncture, the response from acupuncturists often includes five main criticisms. Although superficially persuasive, these criticisms are based on very weak arguments. We shall address them one by one:

1. Acupuncturists point out that we cannot simply ignore those randomized placebo-controlled clinical trials that indicate that acupuncture works. Of course, such evidence should not be ignored, but it has to be weighed against the evidence that counters it, and we need to decide which side of the argument is more convincing, much as a jury would do in a legal case. So let us weigh up the evidence. Is acupuncture effective for a wide range of disorders beyond all reasonable doubt? No. Is acupuncture effective for pain and nausea beyond all reasonable doubt? No. Is acupuncture effective for pain and nausea on the balance of probabilities? The jury it still out, but as time has passed and scientific rigour has increased, then the balance of evidence has moved increasingly against acupuncture. For example, as this book goes to print, the results have emerged of a clinical trial involving 640 patients with chronic back pain. According to this piece of research, which was sponsored by the National Institute of Health in America and conducted by Daniel Cherkin, sham acupuncture is just as effective as real acupuncture. This supports the view that acupuncture treatment acts as nothing more than a powerful placebo.
   
2. Practitioners argue that acupuncture, like many alternative therapies, is an individualized, complex treatment and therefore is not suitable for the sort of large-scale testing that is involved in a trial. This argument is based on the misunderstanding that clinical trials necessarily disregard individualization or complexity. The truth is that such features can be (and often are) incorporated into the design of clinical trials. Furthermore, most conventional medicine is equally complex and individualized, and yet it has progressed thanks to clinical trials. For instance, a doctor will ask a patient about his or her medical history, age, their general health, any recent changes in diet or routine and so on. Having considered all these factors, the doctor will offer a treatment appropriate to that individual patient – that treatment is likely to have been tested in a randomized clinical trial.
   
 

3. Many acupuncturists claim that the underlying philosophy of their therapy is so at odds with conventional science that the clinical trial is inappropriate for testing its efficacy. But this accusation is irrelevant, because clinical trials have nothing to do with philosophy. Instead, clinical trials are solely concerned with establishing whether or not a treatment works.
   
 

4. Acupuncturists complain that the clinical trial is inappropriate for alternative therapies because the impact of the treatment is very subtle. But if the effect of acupuncture is so subtle that it cannot be detected, then is it really a worthwhile therapy? The modern clinical trial is a highly sophisticated, flexible and sensitive approach to assessing the efficacy of any treatment and it is the best way of detecting even the most subtle effect. It can measure effects in all sorts of ways, ranging from analysing a patient’s blood to asking a patient to assess their own health. Some trials use well-established questionnaires that require patients to report several aspects of their quality of life, such as physical pain, emotional problems and vitality.
   
 

5. Finally, some acupuncturists point out that real acupuncture may perform only as well as sham acupuncture, but what if sham acupuncture offers a genuine medical benefit to patients? We have assumed so far that sham acupuncture is inert, except as a placebo, but is it conceivable that superficial and misplaced needling also somehow tap into the body’s meridians? If this turns out to be true, then the entire philosophy of acupuncture falls apart – inserting a needle anywhere to any depth would have a therapeutic benefit, which seems highly unlikely. Also, the development of the telescopic needle sidesteps this question because it does not puncture the skin, so it cannot possibly tap into any meridians. Acupuncturists might counter by arguing that telescopic needles also offer therapeutic benefit because they apply pressure to the skin, but if this were the case then we would also receive benefits from a handshake, a tap on the back or scratching an ear. Alternatively, such pressure on the skin might sometimes detrimentally influence the flow of Ch’i, so such bodily contact might make us ill.
   
 

In short, none of these criticisms stands up to proper scrutiny. They are the sort of flimsy arguments that one might expect from practitioners who instinctively want to protect a therapy in which they have both a professional and an emotional investment. Such acupuncturists are unwilling to accept that the clinical trial is undoubtedly the best method available for minimizing bias. Although never perfect, the clinical trial allows us to get as close to the truth as we possibly can.

In fact, it is important to remember that the clinical trial is so effective at minimizing bias that it is also a vital tool in researching conventional medicine. This is a point that was well made by the British Nobel Prize-winning scientist Sir Peter Medawar:

Although this chapter demonstrates that acupuncture is very likely to be acting as nothing more than a placebo, we cannot end it without raising one issue that might rescue the role of acupuncture within a modern healthcare system. We have already seen that the placebo effect can be a very powerful and positive influence in healthcare, and acupuncture seems to be very good at eliciting a placebo response. Hence, can acupuncturists justify their existence by practising placebo medicine and helping patients with an essentially fake treatment?

For example, we explained that the German mega-trials divided patients into three groups: one received real acupuncture, one received sham acupuncture, and one received no acupuncture at all. In general, the results showed that real acupuncture significantly reduced pain in about half of patients and sham acupuncture delivered roughly the same level of benefit, while the third group of patients showed significantly less improvement. The fact that real and sham acupuncture are roughly as effective as each other implies that real acupuncture merely exploits the placebo effect – but does this matter as long as patients are deriving benefit? In other words, does it matter that the treatment is fake, as long as the benefit is real?

A treatment that relies so heavily on the placebo effect is essentially a bogus treatment, akin to Mesmer’s magnetized water and Perkins’ tractors. Acupuncture works only because the patients have faith in the treatment, but if the latest research were to be more strongly promoted, then some patients would lose their confidence in acupuncture and the placebo benefits would largely melt away. Some people might therefore argue that there should be a conspiracy of silence so that the mystique and power of acupuncture is maintained, which in turn would mean that patients could continue to benefit from needling. Others might feel that misleading patients is fundamentally wrong and that administering placebo treatments is unethical.

The issue of whether or not placebo therapies are acceptable will be relevant to some other forms of alternative medicine, so this issue will be fully addressed in the final chapter. In the meantime, the main question is: which of the other major alternative therapies are genuinely effective, and which are merely placebos?

IN RECENT DECADES HOMEOPATHY HAS BECOME ONE OF THE FASTEST-GROWING
forms of alternative medicine, particularly in Europe. The proportion of the French population using homeopathy increased from 16 per cent to 36 per cent between 1982 and 1992, while in Belgium over half the population regularly relies on homeopathic remedies. This rise in demand has encouraged more people to become practitioners – known as homeopaths – and it has even convinced some conventional doctors to study the subject and offer homeopathic treatments. The UK-based Faculty of Homeopathy already has over 1,4 00 doctors on its register, but the greatest number of practitioners is in India, where there are 300,000 qualified homeopaths, 182 colleges and 300 homeopathic hospitals. And while America has far fewer homeopaths than India, the profits to be made are much greater. Annual sales in the United States increased fivefold from $300 million in 1987 to $1.5 billion in 2000.

With so many practitioners and so much commercial success, it would be reasonable to assume that homeopathy must be effective. After all, why else would millions of people – educated and uneducated, rich and poor, in the East and the West – rely on it?

Yet the medical and scientific establishment has generally viewed homeopathy with a great deal of scepticism, and its remedies have been at the centre of a long-running and often heated debate. This chapter will look at the evidence and reveal whether homeopathy is a medical marvel or whether the critics are correct when they label it a quack medicine.