Acupuncture is All Placebo

Acupuncture is among the most popular alternative therapies in the mainstream medical community. There appears to be a widespread belief that it has been scientifically proven to be a safe and effective therapy, at least for pain and nausea, and possibly for other conditions as well. This belief is based on a decades-long marketing campaign by acupuncture proponents, which has included a great deal of scientific research. As always, however, the devil is in the details, and there is strong reason to believe that a careful reading of the thousands of acupuncture studies strongly supports the interpretation that acupuncture “works” only as a placebo. That is, it only has effects on how we perceive the symptoms of our disease, not the objective disease itself.

The objections to this will include citation of individual studies in which acupuncture appears to be better than other treatments or than sham acupuncture placebo controls. While such studies certainly exist, it is necessary to look carefully at the quality of these and the potential risks for bias and error. When we do this, and when we focus only on the best quality studies, this apparent effect above placebo generally disappears. There is consistent and repeatable experimental evidence that the effects of acupuncture are generated almost entirely by the beliefs and expectations of patients, and that any non-specific physiologic effects are not clinically meaningful. Sticking needles into your body certainly has such physiological effects, but then so does stubbing your toe on the coffee table. This does not a truly effective medical therapy make.

Another objection to the assertion that acupuncture works primarily as a placebo is that this would not explain the apparent effects in non-human animals. However, having evaluated many of the studies that purport to identify such effects, (e.g. 1, 2, 3), they do not do a very convincing job of controlling for sources of error, including the caregiver placebo effect, which frequently leads both pet owners and veterinarians to believe placebo therapies actually have real effects.

There are two recent papers which add to the growing literature identifying the effects of acupuncture as purely placebo effects. The first comes from a somewhat unexpected source, a journal devoted to alternative therapies.

Zheng YC, Yuan TT, Liu T. Is acupuncture a placebo therapy? Complement Ther Med. 2014;22:724-730.

The authors’ conclusion, based on the decades of research into acupuncture, is:

Although current research data are not sufficient for us to ultimately determine whether or not acupuncture possesses a small specific effect, it should be noted that even if this small effect does exist… it will not constitute any change to the fact that what is largely responsible for overall therapeutic effects of acupuncture is actually its robust placebo effect, rather than the assumed ‘small specific effect’…A more likely interpretation of those RCTs of acupuncture is that acupuncture has no specific effect above and beyond a placebo at all;

These authors tend to have a rosier view of the clinical value of placebo effects than I think is warranted, so they contend acupuncture may be worthwhile even if its effects are entirely mediated by belief and expectation. This notion of the “powerful placebo” has some serious problems. For one thing, while it is true that such effects may have value in terms of lessening subjective symptoms, such as pain and nausea, it must be remembered that such effects do not change objective measures of disease or outcomes such as function or mortality. Relieving suffering by fooling people into thinking they are being given a real medical therapy may truly relieve some of their suffering, but it requires deceiving patients, and again it doesn’t make them objectively better even if it makes them feel better. This can lead people into rejecting therapies that might actually improve their health rather than just their perceived symptoms, either because they may feel like they no longer need them or because they fear the side effects of real medical treatment.

As always, we must be particularly wary of employing therapies that act primarily as placebos in veterinary medicine. Most often, such therapies simply make us, as vets and pet owners, feel better, not the patient. I have certainly seen patients in obvious pain who were denied effective treatment for this pain because their owners erroneously believed a placebo therapy like acupuncture or homeopathy was working.

The second paper is the most succinct and comprehensive explanation for why the belief that acupuncture has benefits beyond placebo effects is mistaken.

McGeeney, BE. Acupuncture is all placebo and here is why. Headache. 2015 Feb 6. doi: 10.1111/head.12524. [Epub ahead of print]

The article covers most of the major reasons why doctors may believe acupuncture is more than a placebo, and effectively illustrates why these are false. These are referred to as “sixteen logical traps” plus a couple of added reasons:

Scientific Basis for Acupuncture
Argument From Antiquity
Personal Testimony
Argument From Popularity
More Patient Centered
Underestimating the Placebo Response
Not Appreciating That Procedures Have a Superior Placebo Effect
Not Appreciating the Extra Biases in Subjective Outcomes
The Blinding Problem
“P” Worship
Misinterpretation of Positive Acupuncture Studies
Meta-Analysis Shortcomings
Surrogate Outcomes
Funding
Investigators
Hidden Giant Cognitive Leap
Consumerism
Magical Thinking
The author also acknowledges that these problems are not unique to acupuncture and represent a threat to effective science and evidence-based medicine that is much broader:

This problem is not unique to acupuncture and is seen in other non-scientific alternative medicine therapies which can ride on the coat tails of real science in clinical practice, conferences, and academic journals, the epitome of quackademic medicine. Responsible clinicians need to speak up and not allow nonscientific medicine to go unchallenged…A perfunctory and poorly informed media contribute to the misinformation. Practitioners need to do a better job of discerning truth from information and data available on acupuncture.

The same is certainly true for all therapies, whether those promoted by pharmaceutical companies or practitioners of alternative medicine.

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