Challenging the Skeptics - The Truth about Acupuncture Part 1

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Challenging the Skeptics - The Truth about Acupuncture

 

 

By Brian Benjamin Carter

 

Chinese herbs and acupuncture are a portion of alternative medicine that has

come under fire from skeptics. Skeptics have their own dictionary in which they

define acupuncture and chinese medicine in inaccurate terms. Medical research

and scientific evidence allow us to speak of and practice evidence based

medicine. Here we present most of the acupuncture research and chinese herb

research for effectiveness and safety as well as some alternative medicine

statistics.

 

This article came out of a dispute I had on the radio with a Christian former

new-ager named Marcia Montenegro. Some of the criticisms quoted are hers, others

are standard claims made by skeptics. The original criticisms are in italics and

marked with 'SKEPTIC.' Some of these are numbered to make the responses more

specific and clear. Everything is linked for your convenience.

 

Table of Contents by Topic:

 

The definition of alternative medicine is discussed

Research standards and their application to Acupuncture

The First RCT faithful to both CM diagnosis and treatment and research

standards

Acupuncture is proven by research to work for musculoskeletal conditions,

such as fibromyalgia, myofascial pain, and tennis elbow, or epicondylitis,

acupuncture is efficacious for adult postoperative and chemotherapy nausea and

vomiting, postoperative dental pain, menstrual cramps, breech presentation in

late pregnancy, irritable bowel syndrome, asthma, immune-system problems, severe

vomiting during pregnancy, and cocaine dependence

The myth that substantial research evidence supports conventional medical

practices is debunked

Acupuncture is safe, often safer than standard acceptable medical procedures

Fewer malpractice claims are filed against acupuncturists

A study of 55,000 acupuncture treatments showed 99.9% safety

Some safety issues of biomedicine are reviewed for comparison

Explanation of benefit-risk

Adverse drug reactions

Drug misadventures

RCT defined

Evidence of the biomedical mechanisms of acupuncture

The placebo effect being responsible for acupuncture's success debunked by

another RCT

Response to inflammatory statements about acupuncturists being irrational,

anti-science, conspiracy-oriented, and biased

A bad study design reviewed

History of TCM

Patient Demand, Doctors deceived?

Clarification of yin, yang, and qi

A possible reason for all the disagreement and confusion, and some

perspectives on qi

Perspective on Acupuncture from Andrew Fergusson, the General Secretary of

Christian Medical Fellowship

Is CM a medicine or a metaphysical system?

Spiritual aspects of CM, a harmonious-with-the-Bible example

Good and evil

More about qi

More about yin and yang

Meridians/channels

 

SKEPTIC: Alternative/Blended/Complementary/Integrated Healing

(1) It is called alternative because the technique/drug/herb (1a) has not been

or (1a) cannot be adequately tested, or has been found (1c) ineffective or

dangerous. (2) If it were a safe, tested treatment, it would not be in the

alternative category.

 

RESPONSE:1. This is an inaccurate definition of alternative medicine. " There is

no alternative medicine. There is only scientifically proven, evidence-based

medicine supported by solid data or unproven medicine, for which scientific

evidence is lacking. " - Phil B. Fontanarosa, MD; George D. Lundberg, MD, The

Journal of the American Medical Association, 1998. The section on RCT's provides

the scientific proof, the evidence for acupuncture.

 

* " CAM (Complementary and Alternative Medicine) covers a broad range of healing

philosophies (schools of thought), approaches, and therapies that mainstream

Western (conventional) medicine does not commonly use, accept, study,

understand, or make available. " - from the National Center for Complementary and

Alternative Medicine (NCCAM); - What is NCCAM? See the glossary for more info.

 

* Quick Quote: A PCOM professor who is an ER Doc (MD) says western medicine

should be called alternative, because oriental medicine is preventive, and if

you don't live preventively, the alternative is emergency intervention, often

late in life.

 

1a. NIH Research Standards 1997: " The incorporation of any new clinical

intervention into accepted practice faces more scrutiny now than ever before.

The demands of evidence-based medicine, outcomes research, managed care systems

of health care delivery, and a plethora of therapeutic choices make the

acceptance of new treatments an arduous process. The difficulties are

accentuated when the treatment is based on theories unfamiliar to Western

medicine and its practitioners. It is important, therefore, that the evaluation

of acupuncture for the treatment of specific conditions be carried out

carefully, using designs that can withstand rigorous scrutiny. " - Bensoussan and

others' 1998 IBS RCT was believed to be " the first to incorporate traditional

Chinese diagnosis and treatment methods for IBS into a strictly controlled,

conventional study model. "

 

1c. The Effectiveness of Acupuncture (see RCTs below)

 

2. Is acupuncture safe?

 

* " One of the advantages of acupuncture is that the incidence of adverse effects

is substantially lower than that of many drugs or other accepted medical

procedures used for the same conditions. As an example, musculoskeletal

conditions, such as fibromyalgia, myofascial pain, and tennis elbow, or

epicondylitis, are conditions for which acupuncture may be beneficial. These

painful conditions are often treated with, among other things, anti-inflammatory

medications (aspirin, ibuprofen, etc.) or with steroid injections. Both medical

interventions have a potential for deleterious side effects but are still widely

used and are considered acceptable treatments. The evidence supporting these

therapies is no better than that for acupuncture. In addition, ample clinical

experience, supported by some research data, suggests that acupuncture may be a

reasonable option for a number of clinical conditions. Examples are

postoperative pain and myofascial and low back pain. Examples of disorders for

which the research evidence is less convincing but for which there are some

positive clinical trials include addiction, stroke rehabilitation, carpal tunnel

syndrome, osteoarthritis, and headache. Acupuncture treatment for many

conditions such as asthma or addiction should be part of a comprehensive

management program. " - National Institutes of Health Consensus Statement on

Acupuncture, 1997

 

* Safety of Acupuncture in terms of Insurance Malpractice Claims, JAMA 1998: " In

an analysis of data from malpractice insurers from 1990 through 1996, Studdert

and colleagues18 found that claims against chiropractors, massage therapists,

and acupuncturists generally occurred less frequently and usually involved less

severe injury than claims against medical doctors. " - Phil B. Fontanarosa, MD;

George D. Lundberg, MD

 

* Frequency and Types of Adverse Events in 55,291 Acupuncture Treatments: (see

table) This means 99.8% of acupuncture is performed with no significant minor

adverse events; " During these 5 years, a total of 76 acupuncturists (13

preceptors and 63 interns) participated in the study, and the total number of

acupuncture treatments was 55291. A total of 64 adverse events were reported and

included 11 types of events... The most frequent adverse event was failure to

remove needles after treatment; no sequelae occurred after removal of the

needles. The second most common adverse event was dizziness, discomfort, or

perspiration probably due to transient hypotension associated with the

acupuncture treatment.... We may, therefore, reasonably conclude that serious

adverse events in acupuncture treatment are uncommon in the practice of

adequately trained acupuncturists... . " - Hitoshi Yamashita, Bac, Hiroshi

Tsukayama, BA, Yasuo Tanno, MD, PhD, Kazushi Nishijo, PhD, JAMA

 

* 2 September 2001 Studies of safety of acupuncture in British Medical Journal;

Details of 43 minor adverse events associated with 34 407 acupuncture

treatments; 91 minor events in 31 822 acupuncture treatments; if combined with

the other study above = total of 121,520 treatments with 198 minor adverse

events (0.16% incidence), and no pnemuothoraxes (they are concluded to be

" extremely rare " ).

 

* The most serious adverse events possible with acupuncture are pneumothorax

(puncturing the lung) and septicemia (systemic infection of the blood by

bacteria); " Instruction is given by both lectures and practical training and

includes information about anatomically risky depth of insertion and use of

aseptic procedure for puncturing... Most important, no serious events such as

pneumothorax, spinal lesion, or infection were reported (my note: zero out of

55,291! But even just one would have meant only a 0.002% chance of these

occurring) " - JAMA

 

The Safety of Acupuncture compared with that of Biomedicine:

 

Antibiotic overuse leads to resistant super-bacteria ( " The prevalence of

antibiotic-resistant bacteria in Taiwan is due to the heavy use of antimicrobial

agents in both animal husbandry and clinical practice over the past decades " -

source) as well as intestinal flora imbalance (diarrhea, vaginal candidiasis)

( " Antibiotic use is a short-term risk factor for symptomatic vulvovaginal

candidiasis, either as a first episode or in the form of recurrence. Increasing

duration of antibiotic use is directly related with an increased prevalence of

Candida vaginal infection. " - source) ( " The spectrum of diarrheal disease

associated with antibiotic therapy ranges from antibiotic associated diarrhea

and colitis, to the more severe pseudomembranous colitis, which is always

associated with Clostridium difficile (CD). " - source)

" No drug product is " perfectly " safe. Every single drug that affects the body

will have some side effects. Since the FDA considers both the benefits and risks

of all medications before approval, side effects are generally not serious. For

every drug FDA approves, the benefits are balanced against its risks. In

addition, FDA makes sure the labeling (package insert) outlines the benefits and

risks reported in the tested population. You and your health-care provider

should decide together if the benefits outweigh the risks for YOU. Talking about

your medicines with your health-care provider is just as important and good for

your health as a complete check-up and taking your medicine as directed. " -

FDA/CDER

" The benefit-risk ratio weighs the benefits provided by a drug, versus risks

or safety problems that may be associated with use of the drug. No drug can be

considered to be totally safe. Drugs that are associated with more significant

safety problems are expected to have sufficiently greater benefits to justify

the increased risk. " - source

What does benefit-risk mean to us? A la a discussion of tamoxifen (a breast

cancer drug): " there are categories that, from my perspective, clearly fall out

where the benefits unequivocally outweigh the risks... I think physicians very

frequently discuss risk-benefit ratios for all sorts of treatments, and it

ultimately comes down to a decision between the patient and the doctor. " -

source

 

ADR's (adverse drug reactions):

 

NSAIDS such as ibuprofen - " Gastrointestinal (GI) Adverse Drug Reactions

(ADRs) from the NSAIDs are a major cause of morbidity and mortality in arthritic

patients taking these drugs... Clearly, the need to develop newer NSAIDs with

lower risks of ulcers and bleeding as well as symptomatic ADRs is still

representing a major challenge. " - Jan 2001

high dose steroid use (e.g. in asthma or COPD) leading " high dose of inhaled

steroids may lead to adrenocortical suppression and hence estrogen deficiency in

postmenopausal women, " " the daily dose, but not the duration, of inhaled steroid

therapy may adversely affect bone density " (osteoporosis), " The potential risks

of antiasthmatic inhaled steroid therapy are essentially dose-related and

include oropharyngeal complications such as thrush and dysphonia, and systemic

complications such as hyperactivity, behavioural change,

hypothalamic-pituitary-adrenal axis suppression, facial and weight changes

characteristic of hypercortisonism, cataracts, increased intraocular pressure,

dermal atrophy causing steroid purpura, retarded growth in children and

osteoporosis. A few cases of fracture or acute adrenocortical insufficiency have

been reported. "

 

Drug Misadventures: " Still, we know from studies published to date that drug

misadventures account for: 8-10% of admissions of patients to hospitals, 25% of

admissions to hospitals by persons age 65 years of age or older, 10-15% of

visits to emergency rooms in some urban settings, 4.5 drug order errors per 1000

drug orders in hospitals, Significant decreases in the quality of life (due to

inappropriate prescribing, e.g., of hypnotics for the elderly), 2 in 1000 deaths

in hospitals, and Deterioration or destruction of specific organs. " - source

 

SKEPTIC: (3) Many cited studies to support these methods are flawed, short-term,

based on anecdotal evidence, (4) conducted by believers in the techniques, & (5)

often are not published in a peer-reviewed medical journal. (This section deals

with the evidence for the efficacy of acupuncture, and the quality and amount of

the research as of November, 2001; many skeptics' criticisms are based on the

state of research as of 1997.)

 

RESPONSE: 3. Define RCT - Randomized Controlled Trial. The RCT " is widely

regarded as the most powerful and sensitive tool for comparing therapeutic

interventions.85 " As for RCTs and acupuncture, even 4 years ago (1997), experts

from various fields including MD's, PhD's, and acupuncturists reviewed the

evidence and made what was called the National Institutes of Health Consensus

Statement on Acupuncture - " There is clear evidence that needle acupuncture is

efficacious for adult postoperative and chemotherapy nausea and vomiting and

probably for the nausea of pregnancy. Much of the research is on various pain

problems. There is evidence of efficacy for postoperative dental pain. There are

reasonable studies (although sometimes only single studies) showing relief of

pain with acupuncture on diverse pain conditions such as menstrual cramps,

tennis elbow, and fibromyalgia. This suggests that acupuncture may have a more

general effect on pain. However, there are also studies that do not find

efficacy for acupuncture in pain. "

 

* From same source, we see that even biomedicine (drugs and surgery) is not held

to the same standards to which skeptics want to hold acupuncture: " While it is

often thought that there is substantial research evidence to support

conventional medical practices, this is frequently not the case. This does not

mean that these treatments are ineffective. "

 

* There was no such thing as RCT's in 4500 year history of CM, and there has

only been adequate funding sources for this for 4 or 5 years.

 

Acupuncture RCT's are underway for:

 

Hypertension

Chronic diarrhea in HIV patients

Fibromyalgia

Depression

Knee Osteoarthritis

Dental pain

 

* 1998: " University of California Irvine professor and physicist Zang-Hee Cho, a

member of the highly respected National Academy of Science, the inventor of an

early version of the Positron Emission Tomograph, or PET scan, and a pioneer of

the MRI scanner, both of which have revolutionized our ability to see into the

body and brain, found that stimulation of the vision-related acupoint showed the

same reaction in the brain as stimulation of the eye. As the acupuncture signal

passes to the brain via nerves, it possibly stimulates the hypothalamus, the

" executive center " of the brain, responsible for the production and release of

hundreds of neurochemicals, Cho said. "

 

* 1998 research from the Journal of the American Medical Association: " Cardini

and Weixin found that moxibustion (stimulation of an acupuncture point by heat

generated from burning a specific herb) is helpful for correction of breech

presentation in late pregnancy. Bensoussan and colleagues document that a

Chinese herbal medicine formulation improves symptoms of irritable bowel

syndrome. "

 

* 2000 randomized controlled study showed " asthma patients benefit from

acupuncture treatment given in addition to conventional therapy. Furthermore,

acupuncture performed in accordance with the principles of TCM showed

significant immune-modulating effects. "

 

* " This study suggests that active PC6 acupuncture, in combination with standard

treatment, could make women with hyperemesis gravidarum (severe vomiting during

pregnancy) better faster than placebo acupuncture. "

 

* " Findings from the current study suggest that acupuncture shows promise for

the treatment of cocaine dependence. Further investigation of this treatment

modality appears to be warranted. " -

 

* Cytology of acupuncture points

 

* Enkephalins vs endorphins

 

4. The point of doing RCT's is to eliminate subjectivity- you can't also ask

that the studies be performed only by people who think acupuncture doesn't work-

generally, the people interested in doing research on something are the ones who

are experts about it. Most of the pharaceutical research is done not only by

believers in the drug, but by the very corporation who will benefit from its

sale, but this fact does not invalidate the conclusions of their RCT's.

 

5. Actually, this is not true at all. Many studies of various types have been

published in peer review journals over the years. We must expand upon what you

mean by 'peer' - literally, for acupuncturists, it would mean

acupuncturist-reviewed acupuncture journals (for example). But plenty of RCT's

have been published in medical journals (such as the Journal of the American

Medical Association) as well. The terms complementary, blended, and integrated

are now being used as well since alternative treatments are being combined with

traditional medicine. This makes it more difficult to test the alternative

methods or to know what is really working when the patient improves. This is

true clinically just as much for biomedical practitioners as acupuncturists -

real patients are affected by many factors including environment, drugs,

genetics, supplements, etc. This is another reason for RCT's. The following

studies on the biomedical mechanisms of acupuncture may also help you.

 

Continued: Part 2

 

 

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