Sticking a needle in alternative medicine
Exotic therapies such as acupuncture might make people feel good. But the role of medicine is to cure patients' illnesses, not make them happy.
Alternative medicine is clearly popular (1). In 1990, 60million Americans spent an estimated $13.7 billion on alternative medicine. Americans visited alternative practitioners 425million times in 1990, more often than they visited their primary care physicians. By 1996 Americans were spending $21 billion on alternative medicine. Surveys in the UK reveal annual expenditure of around £1.5 billion on alternative medicine. And alternative practices now find themselves nestled alongside the mainstream with the best hospitals providing aromatherapy, homeopathy, reflexology, acupuncture and so forth as adjuncts or alternatives to medicines that have been developed in laboratories and tested in clinical trials.
It is important to realise that the current vogue for alternative medicine is not really about alternative medicine at all – it is about us. The whole point of alternative medicine is that it doesn’t change; the techniques of alternative medicine were developed several thousand years ago and you are meant to stick with the procedure as a fixed entity. Relative to scientific medicine, which is constantly attacked by scepticism and the proposal of newer and better procedures, alternative medicine is a closed shop. Alternative procedures are what they are and they are not open to development and change: they work because they work, end of story. So if alternative medicine is becoming more popular, then it is clearly not because of any changes in the practice of alternative medicine; it is because of changes in us.
Three things have changed. Firstly, we are physically much healthier. In all corners of the world, except in the former Soviet Union, life expectancy is rising and people are physically healthier for longer stretches of time during their lives. Many factors have contributed to this happy state of affairs, including improved living and working conditions and the rise of scientific medicine that has yielded vaccination programmes, antibiotics, steroids, radiotherapy, anti-viral medicines, and so on (2).
Secondly, and relatedly, having resolved many serious illnesses that blighted lives right up to the middle of the last century, scientific medicine is bumping up against harder problems associated with mechanical wear and tear, ageing and the existential distress of living in ‘a world without meaning’ (3). Although physical health and longevity both trend in a positive direction, there has been a swathe of new problems that are defined by the subjective report of symptoms rather than the objective signs of disease or damage (4). These are disorders such as non-specific low back pain, fibromyalgia or chronic fatigue syndrome – illnesses of the ‘worried well’, or, more precisely, the ‘worried sick’, encouraged by a combination of people being healthy enough to be concerned about symptoms that are unlikely to indicate ill-health and being constantly bombarded with messages about ill-health. It is a rare individual who is unaware of the apparent need to reduce caloric intake, watch their units of alcohol, stay out of the sun, eat five fruit and veg a day, exercise, self examine and heed the occasional twinge as a potential harbinger of disease and death (5). When the banalities of everyday life – eating, drinking, catching the occasional ray of sunshine – are perceived as potential threats to continued life, it is little wonder that people are worried and flock to their GP to parade symptoms without illness.
Thirdly, medicine can be horribly impersonal. Doctors are not much interested in your existential concerns. In fact, your doctor is probably pretty keen to look straight through you to find the disease process lurking below. Of course you are more than your illness and a good doctor will at least attempt to engage you as he or she seeks the source of your sickness. In something like Britain’s National Health Service system, however, which is driven by political and economic targets, the good doctor has no time to see you and barely has enough time to see your illness. It’s much nicer to see an alternative practitioner who takes the time to get to know you, and prepare a treatment that is apparently tailored just for the kind of person you are and the illness or problem you are carrying.
It is tempting to try to deal with the advance of alternative medicine by carrying out randomised controlled trials of the alternative medicine versus a placebo and/or the conventional medical technique. The Guardian‘s ‘Bad Science’ columnist, Ben Goldacre, and other contemporary critics of alternative medicines see much benefit in controlled trials to expose the falsehoods of alternative medicine quackery (6). An excellent example of this approach was recently reported by Haake and colleagues (7). They investigated two types of acupuncture versus conventional therapy for chronic low back pain. The first type of acupuncture was based on traditional Chinese meridians; the acupuncture needles were inserted into appropriate Chinese acupuncture spots. The second type of acupuncture followed the same procedure but the needles were inserted into non-traditional or sham spots. Both these types of acupuncture worked better than conventional therapy, but traditional acupuncture spots did not produce better results than the sham spots. Thus it was concluded that acupuncture needles can be useful to alleviate chronic low back pain but it doesn’t matter where you stick the needles. This finding echoes those of previous studies, including the finding that a cocktail stick is as beneficial as an acupuncture needle (8).
There is a reason why noxious stimulation of the skin might alleviate chronic low back pain and other types of pain. The experience of pain is never the simple and direct response to a noxious stimulus and is always the consequence of a balance of peripheral activity with activity in the spinal cord and brain that can increase or decrease the experience of pain. Whenever you hurt yourself and rub the injured region you are affecting that balance to damp the flow of noxious information and create pain relief. Noxious stimuli can also affect that balance, and that is, in essence, what the acupuncture needles do. Precisely how one noxious stimulus affects another is very poorly understood. But what we do know suggests that acupuncture shouldn’t really work as well as it did in the Haake study. Rubbing an injured area generally provides only mild short-term relief, and rubbing is not likely to replace more conventional analgesics and anaesthetics any time soon.
Why, then, did the acupuncture prove to be more effective than the conventional treatments for chronic low back pain? One possibility is that acupuncture is just better. We might not understand exactly how it works, but perhaps it does work. However, there are some very good reasons to be highly dubious of this interpretation.
Chronic low back pain is a tricky disorder. More than 70 per cent of all cases of low back pain have no identifiable causal pathology. We don’t know why the patients have pain and any diagnosis is based on the report of pain rather than on the observation of damage or disease. These types of pain are increasing at a ferocious rate and it seems unlikely that medical factors alone can adequately explain the large uptake in associated work-related incapacity benefits in most countries since the 1970s (4). Expenditure on these benefits has tripled over the past 30 years despite improvements in life expectancy and morbidity rates over the same period. Currently, in the UK, 70 per cent of recipients of incapacity benefit have health-related problems that are not sufficient to fully explain their incapacity in purely medical terms. In sum, chronic low back pain is more of a psychosocial than a medical problem, and so is unlikely to yield to mainstream medical intervention.
Little wonder, then, that the conventional therapy that was compared with acupuncture was a highly eclectic mix of interventions: ‘The therapies given in the conventional group were physiotherapy, massage, heat therapy, electrotherapy, back school, injections and guidance. In a few patients, therapies included infusions, yoga, hydrojet treatment and swimming.’
My interpretation of this study, therefore, is that at the current moment in time, patients with a non-specific existential disease prefer to spend time with an acupuncturist than with a heat therapist, and it is no surprise that patients report feeling better when they do things that they prefer to do. But it is not the role of medicine to run randomised control trials of stuff that makes people happy in order to prove that stuff that makes people happy tends to make them feel happy. While randomised controlled trials can be justified in some cases, we should not view them as blanket solutions to the problem posed by alternative medicine. Such trials are extremely time-consuming and expensive, and it is often not worth the time and expense to investigate something that is obviously unfounded. Moreover, conducting such a trial can give the impression that a treatment must be worthwhile, given all the expense and time being invested. A negative finding will not necessarily forestall the advocates of alternative medicine and a comprehensively negative finding is always difficult to achieve. Positive effects can be discovered for all sorts of non-specific reasons that can never be fully explained away even if they are almost certainly spurious.
It is also important that medicine does not get too flippant and include alternative treatments because of the argument that they ‘seem to work’ and they ‘can’t do any harm’. First of all, to the extent that these treatments work it is probably via non-specific psychological mechanisms that are parasitical upon prior experiences with medicines that do work. It would be cynical to deliberately mobilise those non-specific responses to provide benefit from a known ineffective treatment. If medicine becomes less than serious about promoting interventions that are known to work via well-understood and well-studied mechanisms, then the authority of medicine is put at risk and the benefits of non-specific psychological responses to medicine may soon be lost.
Secondly, there is the possibility of harm even if the intervention is seemingly innocuous. Most obviously there is the danger of over-zealous advocates of alternative medicine promoting homeopathy to cure cancer, malaria or AIDS and so forth. Less obviously there is the potential undermining of straightforward, bland, but effective medical advice (6). Recently, Hancock and colleagues reported that those presenting with an acute onset of back pain are best treated with advice to stay active and take paracetamol if needed (9). The addition of spinal manipulation or spinal mobilisation and further medication did not provide for a better outcome.
Time is a great healer and most acute symptoms will resolve quite naturally (10). Alternative medicine is partly promoted using the poisonous idea that doctors providing short and simple interventions are fobbing their patients off and not showing the required concern. This encourages patients to focus on their symptoms of ill-health unnecessarily and consume medicines or partake in activities that are unnecessary, unwise or dangerous. This is quite simply an unhealthy state of affairs that actively encourages people to be sicker than they need to be or otherwise would be. In short, medicine needs to recognise that alternative medicine is part of the problem, not part of the cure.
Stuart Derbyshire is a senior lecturer at the School of Psychology at the University of Birmingham, England.
Professor Michael Baum examined the role of complementary medicine in treating cancer and stood up for scientific medicine. Bríd Hehir argued that patient-centred healthcare undermines medical professionalism, and explained the rise and rise of CAM. Joe Kaplinsky warned of the dangers of lazy science reporting. Or read more at spiked issue Science and technology.
(1) Hippocratic Oaths: Medicine and its Discontents, R. Tallis, Atlantic Books (London), 2004.
2. The Rise and Fall of Modern Medicine, J. LeFanu , Carroll and Graf Publishers (New York) 2002
3. A World Without Meaning: The Crisis of Meaning in International Politics, Z.Laidi Routledge (London) 1998
4. Malingering and Illness Deception, P. Halligan, C. Bass, DA Oakley, Oxford University Press, 2003
5. The Tyranny of Health, M. Fitzpatrick, Routledge (London and New York), 2001
6. A kind of magic?, Ben Goldacre, Guardian, 16 November
7.’German acupuncture trials (GERAC) for chronic low back pain’, M Haake, HH Muller, C Schade-Brittinger, HD Basler, H Scafer, C Maier, HG Endres, HJ Trampisch, A Molsberger, Arch Intern Med, 2007;167:1892-1898.
8. ‘A cocktail stick is as good as brief acupuncture in episodic tension-type headache (n=50)’, M Cummings, Acupunct Med 2001;19:56-57
9. ‘Assessment of diclofenac or spinal manipulative therapy, or both, in addition to recommended first-line treatment for acute low back pain: a randomised control trial’, MJ Hancock, CG Maher, J Latimer, AJ McLachlan, CW Cooper, R O’Day , MF Spindler, JH McAuley, The Lancet, 2007;370:1638-1643.
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