Jane McCredie: Acupuncture a placebo? Who cares?

How does one of the world’s leading medical journals come to publish an article that finds a medical intervention is no better than sham treatment but goes on to recommend it as possible first-line therapy?

That was one of the questions being asked in the medical blogosphere after the New England Journal of Medicine recently examined the usefulness of acupuncture in treating chronic lower back pain.

Here’s one part of the article that generated a lot of ire:

Acupuncture … has not been established to be superior to sham acupuncture for the relief of symptoms of low back pain. As a result, it is not often regarded as the first choice of therapy. However, since extensive clinical trials have suggested that acupuncture may be more effective than usual care, it is not unreasonable to consider acupuncture before or together with conventional treatments…

As several commentators have pointed out, you could make exactly the same argument in favour of sham acupuncture, since it was equally successful in outperforming conventional care.

US infectious diseases specialist Dr Mark Crislip, an ascerbic critic of complementary medicine, was one who launched an attack on the NEJM, describing the article as "total tripe" and "tooth fairy science".

The 10-12 acupuncture sessions the authors recommended for a patient whose chronic back pain had not responded to conventional treatment constituted an "unethical, expensive, useless placebo," he wrote.

Obviously, many patients and doctors would disagree with Crislip’s dismissal of acupuncture generally as "prescientific magic".

In fact, it is estimated that at least 15% of Australian GPs claim Medicare rebates for providing acupuncture services.

But the controversy does raise questions about how journals, and medicine more generally, can best engage with treatments that patients swear by, even if they do not meet conventional standards of proof.

A few years ago, I attended an international medical acupuncture conference where one of the visiting experts told me lack of evidence from randomised controlled trials should not be an obstacle to treatment.

He estimated about 20% of patients with neuropathic pain achieved adequate relief with acupuncture. "Lack of evidence does not mean lack of effect," he said.

It may be counterintuitive, but, if a patient can afford an intervention that improves symptoms (whether or not that is via the placebo effect) and does not cause side-effects, is a doctor doing the right thing in opposing it?

Some argue a hostile approach might actually do more harm.

It’s unlikely to deter the patient from using their beloved therapy, but it might stop them from telling their doctor such things in future, increasing the risk of therapy interactions and other problems.

Jane McCredie is a Sydney-based science and medicine writer. She has worked for Melbourne's The Age and contributed to publications including the BMJ, The Australian and the Sydney Morning Herald. She is also a former news and features editor with Australian Doctor magazine. Her book, The sex factory, on the science of sex and gender will be published by UNSW Press later this year.

Posted 30 August 2010