On Monday, I blogged about a “study” that purported to show that acupuncture was as effective as analgesics for treatment of pain caused by migraine, sprained ankles and lower back pain.



The problem with this “research” was it has yet to be published – indeed the news report announcing it said the results were not even completely analysed. Except for the fact that this was mentioned, the process of going directly to the press could be in breach of the Australian Code for the Responsible Conduct of Research.

Section 4.12.1 says, “Discussing research findings in the public arena should not occur until the findings have been tested through peer review. In discussing the outcomes of a research project, special care should be taken to explain the status of the project – for example, whether it is still in progress or has been finalised”.

Regardless, this represents very poor practice in my opinion, and I can only presume the researchers did this owing to the lack of critical controls (specifically, sham acupuncture or some other acupuncture control) in their 3 years $400,000 study, meaning they probably won’t get this published. At least not anywhere decent anyway.

Well, now I have an update. One of the researchers went on radio to talk about this, and his comments were like a bingo card of logical fallacies. I couldn’t bring myself to listen to the broadcast for fear of #stabby, so a very kind clever person transcribed it for me. So here dear reader, I present it to you, with my comments in parentheses.

Audio is here

BEGINS

Chris (Announcer): Now chronic pain is something many people have to deal with on a daily basis and it can be just as debilitating as anything they’re suffering.

Well a new study out of Melbourne has shown some very promising developments when it comes to pain relief, and it doesn’t involve any new drug.

The Chinese therapy of acupuncture is currently being put tot the test across four of Melbourne’s top hospitals as well as RMIT University; and before you roll your eyes at the idea, let me just tell you about the results, because so far the results have been pretty amazing!

The study is currently indicating that acupuncture could be just as good as those serious drugs we take to relieve pain. [NB study is NOT published, results still being analysed, thus these claims can not be made]

For instance, Panadeine Forte, Votaren even Valium which is quite a breakthrough in the area of acupuncture; could acupuncture be the future in pain relief?

On the line with me now is Mark Cohen from the Health Innovations Research Institute at RMIT University. Mark, welcome to the program.

M Great to be with you Chris.

C The results from this study, pretty promising so far?

M Well they are very promising [not analysed, not published], and these come on the back of a lot of experience [anecdotal, NB there is nothing wrong with instigating a study based on observations, this is how much of science happens, but especially where pain is concerned, you must have very strict controls in place to ensure you can differentiate between placebo and any effect. This was not controlled in this study] that we’ve had in Melbourne of Emergency Medicine physicians who have been trained in acupuncture an who have been using it in the Emergency Department with great effect, and then we decided, well let’s put this to the test, and we’ve compared acupuncture for migraine, back pain and ankle sprain to acupuncture plus drugs, or just drugs alone.

C Interesting. So tell me about just acupuncture alone? You think that it can give you pain relief equivalent to something like a Panadeine Forte?

M Well, in this study we showed that they are basically equivalent [no, you didn't. There's an old saying in science, if it's not published you may as well have not done it] , so that there was no difference between Panadeine Forte, and not just Panadeine Forte, even opiates, things like Pethidine, and you know, harder painkillers we often get …

C Uh huh

M …in Emergency Departments

C What about when you put these two together? Acupuncture, and some of these harder anti-pain drugs?

M Well again, together we found that… and our results are preliminary [read: unpublished], but we together found that more effective than either one alone. But, er, with the way we do statistics, and we’re still finalising the statistical analysis, is at the moment what we can say is they’re deemed equivalent. So acupuncture was deemed equivalent to pharmacotherapy [not], which is a whole range of um drugs that are used, according to a protocol in each Emergency Department

C That’s very interesting, but can you please just explain to people; I know, I’ve had acupuncture on a couple of occasions in my life for a chronic back area that I have that, er, gives me a great deal of trouble…

M Uh huh

C ..but when I’ve had acupuncture, I tell you what, I’ve gone without a pain in that area for sometimes years. So I, I , I, would opt for acupuncture, um, if I got that pain back again. But just give people an idea of what acupuncture is and what it does.

M Well acupuncture, I mean, has been used for thousands of years [logical fallacy, argument from antiquity and also disputed], and it hasn’t just been used in China, a lot of different traditional medicines have what is called counter irritation, where you irritate one part of the body with a needle, or heat, or pressure, to relieve pain in another part. Acupuncture, modern acupuncture, involves usually disposable needles inserted in precise spots, and often the best spot to put a needle is the most intensely painful spot, so you put, you know, a few needles that vary on the condition and where the pain is that you’re trying to treat, into the body, often then you twiddle the needles, or you turn, and lift them up and down, and you get this sensation that the sensation that the acupuncturists call “Dead Chi”…

C That’s right!

M …or “A Chi” and it’s a feeling of numbness, and fullness, and distension, and a bit of soreness; it’s not quite like electricity, but…

C But it’s not always pleasant, I’ve gotta say Mark

M …it’s not entirely pleasant, but it’s not directly painful…

C No

M …more sore than pain, and it feels a bit forward, sometimes that feeling travels, you know, along the body…

C Yeah

M …but that feeling generally means you’re going to get a good result, and there’s, there have been a lot of animal studies that have shown that when you insert needles, acupuncture needles, you get release of endorphins and a lot of other neurochemicals which are your body’s own natural painkillers

C So you allow the body to take the pain away from the body?

M That’s right, so that you’re basically alerting to the body, alerting to the body, saying hey, something’s going on here, deal with it.

C How, how popular is acupuncture? [note: just because something is popular doesn't mean it works. Plenty of people believe in an invisible sky fairy, doesn't make it real. Your logical fallacy is argumentum ad populum]

M Well acupuncture’s very, I mean, China, and around the world it’s used very very commonly; even in Australia I mean most suburban areas would have a Chinese medicine practitioner practising acupuncture.

C Does your average GP think that acupuncture is a bit “witch doctorish”

M Well, no, I did a study about ten years ago asking GPs their opinion about a whole range of complementary therapies, and acupuncture was probably the most accepted, and about 20% of Australian GPs have some training themselves in acupuncture [again, argumentum ad populum], and acupuncture has had a Medicare rebate item since the early eighties, so, I mean, you get, you can get acupuncture on Medicare [doesn't mean it works, you can also claim homeopathy on Medicare] when it’s done by a doctor, or, you know, you can get it done by a traditional Chinese therapy…

C So it’s interesting, if you’ve got chronic pain, and you’re taking drugs consistently, over and over again, it can’t do much for your kidneys or your liver, could it?

M Well, that’s right, and one of the issues is not just chronic pain, but what we tested acute pain in the Emergency Department, and the drugs that are used to treat pain, all have fairly serious side effects, and even Panadeine Forte, I mean they make you very constipated and nauseous, and often, when you’re giving an opiate drug, for example, you can’t just give an opiate drug, you have to give an anti-nausea drug at the same time…

C Yes, yes

M …and other drugs to stop you getting constipated, because then you get abdominal pain and bloating, so, the drugs themselves, and also in an Emergency Department you can’t just give someone a dose of opiates and then send them home, you’ve got to watch them for four hours because they’re going to be drowsy, and so there are serious side effects to the drugs, so having an alternative to drug therapy, that’s not a drug, is actually a great boon for many many patients.

C Yeah. Interesting. And so you must be excited by this, but there’s more to do?

M Well, there’s certainly more to do [like, er publish the results?], and, and um this is, we did this in four hospitals, there are two private hospitals, Cabrini and the Epworth, and two public hospitals, the Northern and the Alfred, and um, you know the results are the same across the hospitals [no way to tell with no acupuncture controls], now the question is, if, if acupuncture’s going to be delivered commonly in the Emergency Department, who’s going to deliver it, can we train emergency physicians to do acupuncture…[er, easy tiger, maybe you should publish the results first]

C Yeah, right

M …you know, do we bring in other acupuncturists, what level of training do they need, but, it’s it’s quite telling that in Australia I know at least three emergency physicians who have done their own training in acupuncture [is it? your logical fallacy is argument from authority], and Michael Ben-Meir, who’s now one of the, he’s now head of the Cabrini Emergency Department, now he’s a trained acupuncturist, and he uses acupuncture pretty much as a routine therapy for patients who come to Cabrini Hospital in Melbourne

C A great devotee, all right, good luck, and thank you very much, and well done with what you’ve discovered.

M Yeah, well thanks, Chris, um yeah it’s encouraging, and we hope, we hope you know hopefully this will help a lot of people who are in pain and um give them another option… [when it's published, maybe] 

C Yeah, absolutely. Thank you, Mark!

M It’s a pleasure.

C Mark Cohen from the health Innovations Institute at RMIT University. So maybe it’s not about taking drugs to get rid of that pain that you may have, maybe you’ve got to think outside the square and think about acupuncture, it’s not that witch-doctorish as you may think. We’ll take some calls on that.

[Calls are between DJ and public]

ENDS

I find this practice extremely unethical and irresponsible and the researchers involved should be ashamed. The media also deserves a slap upside the head, as described eloquently here by my colleague Mick Vagg. I’ve also submitted a letter to the editor of the paper who reported the study, penned with my colleague John Cunningham, and I will publish it here if it doesn’t make the Sunday paper.

I don’t expect we’ll ever see this research published, but it doesn’t matter anymore, the horse has has bolted. People think acupuncture works as well as drugs, based on some very questionable evidence.

In this broadcast, Prof Mark Cohen did not make it sufficiently clear that these results have not been published and that the correct controls were not used = bad practice and bad science.

Thanks to Steven Novella who also blogged this here


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  • Dan Keown

    Ha ha ha

  • DrRachie

    I’m still not gonna buy your book Dan.

  • Dan Keown

    Only just saw this question. It’s a stupid question coz the answers in my book, read it and you’re realise how ignorant your knowledge of the body is.
    Second question: so what?

  • Dan Keown

    Let’s get this straight:

    Firstly, the author ( or possibly moderator as the author uses a pseudonym?!) refuses to answer questions about their funding. The first rule of scientific inquiry has been breached: competing interests.

    Secondly, the author is a cell biologist yet appears to have no knowledge of the gaping hole at the centre of cell biology: how does the embryo self organise? Rather than show interest at a powerful new concept that partially explains this, she mocks it. How scientific.

    Thirdly the author talks about placebo as though she knows what it is, whilst having no idea whatsoever

    What a joke. None are more blind than those who do not realise it. If you cannot see the gaping inconsistencies in your world view, well… take your pay checks and be happy. Ignorance is bliss.

    Goodnight and goodbye.

  • DrRachie

    How do you be a ED physician whilst believing in invisible magic lines and energy? Serious question.

  • DrRachie

    “Shall we just call this Qi instead, because that is what it is.”

    Bwahahaha. No Dan, we’ll call it electricity.

  • Dan Keown

    That’s called not answering the question. How do you be a cell biologist without the endgame being pharmaceutical products?

  • Dan Keown

    Remind me about that invisible energy moving in your tablet that makes it work again?. Sounds like voodoo science to me. I prefer the invisible energy in the body that makes it work. Heres a video from New Scientist showing it… http://www.tinyurl.com/qiproof.

    You can read more in the book that Dr Rach kindly plugged for me.

  • Dan Keown

    Here’s some electricity (visible) in the body. Oh look, the NewScientist says this electricity tells a frogs face where to form. Shall we just call this Qi instead, because that is what it is.

    http://www.tinyurl.com/qiproof

  • Andy

    I’m pretty sure people have found ways to measure electricity – though maybe I should look into that. I’m also fairly certain that I’ve seen electricity come out of wires when I’ve done something I wasn’t supposed to. Actually, it’s often a good reminder not to do that thing again – except for entertainment purposes.

    Your apparent alternative preference to reality is like insisting fairies run through the wiring in your home to make your appliances work. You know someone can’t disprove it because you also insist it can’t be tested by normal means. You add further that anyone who says it might be elves, not fairies, because a pro-fairy test didn’t attempt to differentiate, is a fundamentalist who would be better off accepting that fairies are real because some people believe in them.

  • Andy

    Oh come on Dr ‘Maggie’ Rachie Rachel Dunlop – or whatever your real name is.

    I know how this works. I had a friend who works in electronics. He spent years developing new and faster ways to communicate with electronic gadgets. But it was so obvious to me that he could only do this if he was employed by Big Computa or Big Phone and therefore his work – and that of his colleagues – couldn’t be trusted. He only did it for money and the intent was always to have something “amazing” produced by some big corporation.

    To this day I never trust any electronic device researched and designed by people who work in electronics.

    …posted on my stone tablet.

  • DrRachie

    Lol. Google is your friend Dan.

  • Dan Keown

    Seriously though, if you are a cell biologist can we untangle your funding? Invariably, eventually, it will come from selling pharmacological substances. No one else is interested.

  • Dan Keown

    And you don’t understand medicine or the ‘placebo effect’, or how 10 000 000 000 000 cells co-operate without using vague mystical forces like ‘Qi’. But, you act like you can know all the answers through trials! That’s why I call it ‘scientific fundamentalism’. It’s like someone refusing to believe in electricity working a computer because they can’t see it. Very frustrating.

  • Dan Keown

    Oh hang on, you didn’t write the post?! You’re just the moderator. Unclear as the person who wrote it used a pseudonym.

  • Dan Keown

    Who else has an interest in cell biology? If you work for a charity then their links with Pharma are legion ie the endgame of where you work is to produce a pharmacological compound (to sell to the public). Tell me I’m wrong, more than happy to admit it.

  • Pingback: » Update on Acupuncture in ED – Letter to the editor

  • DrRachie

    So you don’t understand how to design trials. That’s ok, but why not just say so.

  • DrRachie

    How do you figure that Dan? Wow, your knowledge of what scientists do is very poor indeed.

  • Dan Keown

    Ps talking of conflict of interest I understand now why you ‘choose’ not to cover pharma’s malfeasence… As a cell biologist you must be employed by them!

  • Dan Keown

    For starters you can’t define ‘placebo effect’ yet use it like you know what it is. I would define it as the ‘therapeutic encounter’: that’s why it’s so variable. When you do that then it doesn’t really matter whether you ‘control’ for ‘placebo’. Placebos (an inert substance taken as a substitute for an active ingredient) are uniquely suited for pharmacological trials. Scientists are always getting het up about having a placebo, but they need to understand the effect better first.

    Anyway, all of medicine is ‘placebo’ ie therapeutic encounter; and the art of medicine involves boosting that as much as possible. This is what good clinicians understand that scientists don’t.

    As a cell biologist (you are aren’t you?) you should read my book, I think you’ll learn something.

    Best wishes,

    Dan

  • DrRachie

    Dr Dan, since I wrote the blog I’ve seen this (see link), which is a detailed description of the methodology. Given your expertise in acupuncture can you please tell me if this is controlled properly? How can this study design possibly discriminate between placebo and effect given the lack of controls?

    http://www.trialsjournal.com/content/12/1/241

    You’re trained in acupuncture, where do you see the flaws in this study design?

    Which brings me back to “Can’t possibly show?” This study cannot possibly distinguish between placebo and effect because it is not sufficiently controlled. A pain trial nonetheless – a condition highly susceptible to placebo – not controlled for placebo. Worthless exercise wouldn’t you say?

  • Dan Keown

    ‘Why is that a problem?’

    Because a) as u point out you haven’t seen the study so how can you say it doesn’t work b) because ‘placebo effect’ or not it almost certainly does

    ‘Can’t possibly show?’ Is scientific fundamentalism. Like saying that you can’t possibly prove that birds fly without showing me a study. As said, scientific fundamentalism.

    ‘Why should I cover this (BigPharma)?’ If I have to explain this… Nah, forget it, some people can’t see the woods for the trees.

  • DrRachie

    Oh, and I see you have a very clear conflict of interest in positive studies of acupuncture – you’re selling a book on it and you practice it. Makes sense now that you’re not interested in negative evidence.

    Dr Daniel Keown has worked as a registered doctor since graduating with a medical degree from Manchester University in 1998. In 2008, he completed a degree in Chinese Medicine and Acupuncture from Kingston University. Daniel is a member of the British Acupuncture Council and has studied alongside the renowned Dr Wang Ju-Yi at the Institute of Channel Diagnosis in Beiing. He lives and practises in Tunbridge Wells, UK.

    http://www.amazon.com/The-Spark-Machine-Acupuncture-Mysteries/dp/1848191960

  • DrRachie

    “Jesus. Why don’t you do something useful?”
    Thanks for the tip Dan, but I figure these posts will assist people in making an informed decision should they happen to Google acupuncture and pain relief, Melb study. I think it’s fair for people to be aware that this study does not show what the authors or the media say, so if patients hit this site, at least they are armed with the correct information so they can make an informed choice. Why is this a problem to you?

    “Patients love acupuncture”
    Sure they might but that’s not what this post is about – it’s about a terrible study that can’t possibly show if acupuncture works or not, owing to the lack of controls.

    “Useful idiot or idiot? Which one are you to the pharmaceutical companies? You’re certainly not a patient advocate as the critical issue here is choice.”
    I agree with you on this point, choice is extremely important, and when I make a choice I like to have all available data in front of me in order that I may make an informed choice. So this blog actually assists with that process. Glad you agree.

    “The thing is, you scientists try and tell us clinicians what works. Let me give you a little tip, we deal with real people not numbers.”

    Forgive me, but we don’t tell you what works, but we provide the evidence for you guys to make clinical decisions. No one can forbid you from that. The thing is, there’s not much evidence that acupuncture works better than placebo. And patients have a right to know this don’t you think? Also, your knowledge of what scientists do is apparently lacking because we also deal with people. I’m surprised you don’t know that.

    “Why not tackle how pharma hides trial results, or how pharma manipulates the ‘research’ system? You want to be sceptical? There’s an elephant in the room.”
    Umm, this post is not about that. And thanks for the idea, but given it’s my blog, I’ll cover what I like. Why don’t you cover it if it bothers you so much? In lieu of that, I suggest you look at the work of Dr Ben Goldacre (UK) for ongoing analysis of this subject. In fact he wrote something about this only yesterday for the UK Guardian.

    Thanks for your word of wisdom Dan.

  • Dan Keown

    Jesus. Why don’t you do something useful? Patients love acupuncture. They don’t like GI bleeds, heart attacks and strokes which are all caused by chronic use of painkillers.
    Useful idiot or idiot? Which one are you to the pharmaceutical companies? You’re certainly not a patient advocate as the critical issue here is choice. The thing is, you scientists try and tell us clinicians what works. Let me give you a little tip, we deal with real people not numbers.
    Why not tackle how pharma hides trial results, or how pharma manipulates the ‘research’ system? You want to be sceptical? There’s an elephant in the room.