Acupuncture Is Almost Certainly Clinically Irrelevant

An excellent paper written by acupuncture skeptics David Colquhoun and Steve Novella was recently published in a journal called Anesthesia and Analgesia. It is part of a written debate hosted by the journal in question between proponents of acupuncture and skeptical scientists who consider it to be clinically irrelevant. The article is aptly titled Acupuncture Is Theatrical Placebo. Anesthesia and Analgesia is an open access journal, so the full paper is available for free on the journal website.

However, readers should not interpret the existence of such a debate as if the science was equivocal or undecided. On the contrary, as Colquhoun and Novella demonstrate in their paper, there have been thousands of studies carried out on acupuncture and no consistent evidence of clinical efficacy for any condition has been found. Do not mistake denialism for debate, as the saying (attributed to Hoofnagle) goes. Just because two differing positions are expressed with equal emphasis does not mean that the truth lies between them. Sometimes, one side is simply wrong and this is the case for acupuncture.

This is a point-by-point summary of main facts and arguments laid out in the Colquhoun and Novella paper (read the full text available at the link above for additional details).

The history of acupuncture: Although its roots go back a long way, acupuncture was banned by emperor Dao Guang in the 1820s and popularized by the dictator Mao Zedong in the late 1960s as an effort to mask the lack of medically trained professionals in China and prop up Chinese nationalism.

The open heart surgery anecdote: the author and scientist Simon Singh revealed that the open heart surgery performed in China in the 1970s (allegedly only using acupuncture for pain relief) was done on a patient who got multiple, strong sedatives and local anesthesia.

The single study fallacy: because of conflicting and inconsistent results of individual studies, it is better to look at meta-analyses that look at combined data.

Real acupuncture often does no better than sham acupuncture: large studies that look at different chronic pain conditions show that real acupuncture does not provide any better clinical outcomes than sham acupuncture. This shows that acupuncture is a placebo effect and not clinically useful for patients with chronic pain conditions.

Any observed effect of acupuncture is very small: Those meta-analyses that indicate that real acupuncture is better than sham acupuncture only show a very small benefit, not large enough to be of clinical significance.

Positive acupuncture trials are often methodologically flawed: they lack proper blinding so the patient knows if he or she is getting the real treatment or placebo and so does the practitioner. Therefore, those studies cannot differentiate between an actual effect and a placebo response. This means that the beneficial effect of acupuncture for pain is even less than small.

No credible evidence that acupuncture is effective for: rheumatoid arthritis, smoking cessation, irritable bowel syndrome, weight loss, drug addictions, asthma, chronic pain, depression, insomnia, neck pain, shoulder pain, stroke etc.

When acupuncture seems to work, it is probably due to regression to the mean: individuals with chronic conditions have better days and worse days and it fluctuates back and forth. One is more likely to see an unscientific practitioner on the worse days and so this might coincide with a fluctuation back to the average experience naturally without it being due to the acupuncture. That is one reason why proper controls are needed.

Alleged effectiveness of acupuncture against PONV due to ineffective antiemetic control one meta-analysis of acupuncture appeared to show that it was beneficial against postoperative nausea and vomiting (PONV). However, there are reasons to suspect that the antiemetic control substance itself is not effective as major fraud has been discovered in the research backing the supposed efficacy of the antiemetic.

Here are the main conclusions of the Colquhoun and Novella paper (my bold):

It is clear from meta-analyses that results of acupuncture trials are variable and inconsistent, even for single conditions. After thousands of trials of acupuncture and hundreds of systematic reviews, arguments continue unabated.

[…]

Since it has proved impossible to find consistent evidence after more than 3000 trials, it is time to give up. It seems very unlikely that the money that it would cost to do another 3000 trials would be well-spent. A small excess of positive results after thousands of trials is most consistent with an inactive intervention. The small excess is predicted by poor study design and publication bias.

[…]

The best controlled studies show a clear pattern, with acupuncture the outcome does not depend on needle location or even needle insertion. Since these variables are those that define acupuncture, the only sensible conclusion is that acupuncture does not work. Everything else is the expected noise of clinical trials, and this noise seems particularly high with acupuncture research. The most parsimonious conclusion is that with acupuncture there is no signal, only noise.

Although acupuncture has more or less gotten the final nail (needle?) in its coffin, the authors think that acupuncture will still exist as a “voluntary self-imposed tax on the gullible”. I personally think this is a bit cynical and would prefer that skeptical efforts were put to educating those individuals about the lack of scientific evidence for efficacy, the risks with acupuncture and so on. After all, such gullible individuals (who may be somewhat desperate for relief from their chronic pain conditions) would still be the victim of pseudoscience (even if practitioners did not openly make extravagant claims).