The headline to a Guardian story this morning reads: “Acupuncture useful but overall of little benefit – study shows”. Actually that is not what the study showed at all. I reported on this study in the Daily Mail yesterday and read the report carefully.
Instead the study showed two positive things about acupuncture. Firstly that it was twice as effective as the standard treatment of pain-killing drugs and exercise that sufferers are likely to be offered by their doctor. To describe this as “of little benefit” is a bizarre interpretation.
Secondly it found that the beneficial effect of acupuncture could not be explained by the placebo effect. The Guardian article, however, quotes Professor Edzard Ernst, indefatigable critic of all forms of CAM (complementary and alternative medicine), as saying precisely the opposite: “this study clearly showed that the effects of acupuncture were mostly due to placebo.”
This is barefaced spin and part of a long running battle. For several years there has been a heated debate as to whether the benefits of acupuncture are “real” or simply due to a placebo – the hopes of the patient, the reassuring practitioner etc. Several big trials have found little difference between sham or placebo acupuncture (with needles put in at random) and the traditional version.
The purpose of this latest trial, using a particularly rigorous statistical technique (see my Daily Mail article), was to discover if there was a genuine difference between the real and the sham versions. It found there was.
Professor Ernst has always tied his colours to the mast of science when it comes to CAM. A reasonable summary of his position would be: “Treatments like acupuncture and homeopathy have no scientifically meaningful mechanism by which they work. They should be tested in proper trials like all drug treatments and if they show up as better than a placebo then we have to accept them as having a genuine effect.”
Yet when a large re-analysis of 29, high quality, randomised trials conducted at eight centres in the USA, the UK and Germany finds there is an effect, the “scientific” response of Professor Ernst is to fall back on his personal belief and say it’s “mostly” due to placebo. That’s not science, that’s politics or possibly religion.
No level playing field
What’s infuriating to clinicians who support the use of acupuncture because of the benefit they see it has on patients, is that the likes of Ernst, while claiming to have an impartial scientific view, don’t operate a level playing field. Everybody who has to deal with chronic pain knows that the existing drugs to control it have a range of unpleasant and dangerous effects such as internal bleeding and addiction.
It is also clear from the research that acupuncture is twice as effective as conventional treatment. The patients in the recent analysis were all on regular painkillers before they started on acupuncture and the conventional version – cut the patient’s rating of their pain by half.
Desire to score points
It’s in this context that it is hard to escape the conclusion that Ernst’s interventions are motivated more by a desire to score points against CAM than to help patients in the real world. The report, published on Monday by the National Patient Safety Agency on the safety of acupuncture given on NHS, is an example. Ernst was one of the investigators.
It found 325 cases of patients being harmed by acupuncture in a two year period. The most serious events were five cases of collapsed lung as a result of an acupuncture needle accidentally penetrating patients’ chests. However it concluded that “in 95% of cases the harm was classified as ‘low’ or ‘no harm.’
But then those involved warned that; the true numbers coming to harm is likely to be far higher because the study only included those who have acupuncture on the NHS. Ernst himself commented: “the study showed for the first time that acupuncture on the NHS is not devoid of risk.”
2000 die from aspirin
Keeping the harm of any treatment to a minimum is of course a good idea. But since research also shows that only between 1% and 10% of drug side-effects are ever reported and that the damage done by pharmaceutical painkillers is considerable – 2000 people dying from the effects of aspirin-type drugs every year alone – a more clinically useful conclusion might be that acupuncture is remarkable safe.
Actually you can’t say that for certain because this report omitted the key fact that would have made it useful. It didn’t say how many people actually get acupuncture on the NHS. If it’s only a thousand then the figures are alarming, but if it is a million then the appropriate response would surely be the one used in response to reports of drug side-effects – the benefits outweigh the harm.
‘The only data we have on numbers treated comes from Germany,” says ’Dr Mike Cummings, medical director of the British Medical Acupuncture Society. “Research there has found just two cases of a punctured lung out of 2.2 million treatments. He also commented that the risk of puncturing the lung is well-known and anyone trained by the Society knows to warn about it.
Ernst and his allies like to present the issue of whether clinicians are practising evidence based medicine as a simple black and white issue. It clearly isn’t.