May 07 2009

Obama’s Health Initiative – Acupuncture for Migraine

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Comments: 17

It must be tough being a highly visible politician – specifically taking questions from the public. You can get hit with highly technical questions in any area, often posed by someone with a narrow agenda and a great deal of information with which they can plan rhetorical mines. I don’t expect politicians to have all the technical details for any such issue at their fingertips. Experienced politicians, however, have learned how to handle such situations – the first rule of which is not to pull facts out of your butt.

George Bush’s most famous such gaffe, in my opinion, is when he said that the “jury is still out” on the question of evolution. Right – only greater than 98% of all scientists agree that evolution is a scientific fact, but we’re still waiting on the other 1% or so of hold outs.

Obama is not likely to get tripped up on the evolution issue, but he is vulnerable when it comes to science and medicine. Unscientific medical modalities and practitioners have found allies on both sides of the political aisle. The impending health care reform has also mobilized the CAM (complementary and alternative medicine) troops who are trying to twist the health care agenda to serve pseudoscience.

At a recent town meeting Obama received the following question and gave the following answer:

Q    I’m a licensed acupuncturist and licensed massage therapist in Florissant.  And so –

THE PRESIDENT:  I could use one right now.  (Laughter.)  My back is stiff.  I’ve been working hard.

Q    I’ll be happy to help you.  (Laughter.)  And this kind of fits into what you were just talking about as far as health care.  I’m wondering, as a practitioner of Oriental medicine, knowing that the National Institutes of Health and the World Health Organization has discovered through their studies that alternative medicine often is more cost-effective and very effective, how will alternative medicine fit in your new health care program?

THE PRESIDENT:  Well, look, my attitude is that we should — we should do what works.  So I think it is pretty well documented through scientific studies that acupuncture, for example, can be very helpful in relieving certain things like migraines and other ailments — or at least as effective as more intrusive interventions.

I will let the science guide me.  We just swore in an outstanding new Secretary of Health and Human Service, Kathleen Sebelius, former governor of Kansas.  (Applause.)  It’s good to see that a Jay Hawk got applause on this side of the border here. (Laughter.)  But she’s going to do an outstanding job.  And my charge to her is, as we’re going through health care reform let’s find out what works.

I think one basic principle that we know is that the more we do on the prevention side, the more we can obtain serious savings down the road.  So giving children early checkups, making sure that they get immunized, making sure that they are diagnosed if they’ve got eyesight problems, making sure that they’re taught proper nutrition to avoid a life of obesity — those are all issues that we have some control over.  And if we’re making those investments, we will save huge amounts of money in the long-term.

Unfortunately, the hardest thing to do in politics — and certainly in health care reform — has been to get policymakers to make investments early that will have long-term payoffs.  Because people — their attitude is, well, I’ll be out of office by the time that kid grows up; and, the fact that they’re healthy, that doesn’t help me.  And in the private sector insurance system, oftentimes insurers make the same calculation. Their attitude is, well, people change jobs enough for us to pay for the preventive medicine now when the problem may not crop up for another 20 years and they’ll be long out of our system, so we don’t want to reimburse it because it will make things more costly.  That’s the logic of our health care system that we’re going to have to change.

The recovery package put a huge amount in prevention.  We are, in our budget, calling for significant increases in prevention.  And my hope is, is that working in a bipartisan fashion we are going to be able to get a health care reform bill on my desk before the end of the year that will start seeing the kinds of investments that will make everybody healthier.  All right?  (Applause.)

With regard to the question – of course it is a loaded question which contains a false premise. First it treats “alternative medicine” as if it were one entity. The questioner claims that “alternative medicine works,” but this is a meaningless statement. Which CAM modalities work for which indications? Each modality has to be considered in its own right. This is precisely why the category of CAM itself is counterproductive and unscientific. It exists only to promote modalities which are not supported by science and evidence, because if they were they would not be “alternative” medicine, they would be medicine.

There is also no evidence to support the claim that any particular CAM modality is cost effective. They may be cheaper up front (but not always), but in order to be cost effective a treatment must be effective.

The bulk of Obama’s response is reasonable (from a scientific point of view – I am not commenting on his politics because that is not the focus of this blog). He says he wants to use what works and he will let science be his guide. These are both laudable principles – I hope he sticks with them.

He also did what politicians typically do, quickly steer the answer to prefab talking points, regardless of the specific question.

But he opened up by doing what seems to me throwing a bone to the questioner by stating that acupuncture works for some indications, like migraines. That, to me, was a huge gaffe, and completely unnecessary. Obama made a specific conclusion about scientific evidence in a highly technical area. I wonder if this is something he just thinks he knows because he read it somewhere, or if he was specifically told this by an adviser (in which case he needs new advisers).

At the very least it should be clear that such a claim is controversial, not accepted science. But confusion on this issue (acupuncture and migraine) is understandable given the amount of misinformation out there. Even worse than mainstream press misinformation is the fact that acupuncturists and CAM advocates are the ones doing many of the reviews, including for the Cochrane database (an evidence-based medicine database). This is a serious problem. I wonder if the Cochrane Collaboration would have pharmaceutical companies conducting reviews of the efficacy of their products.

Let’s look at the 2009 Cochrane review of acupuncture for migraine headache.  The lead reviewer is Karl Lunde whose affiliation is given as Centre for Complementary Medicine Research, Department of Internal Medicine II, Technische Universitaet Muenchen. The authors of the review broke the eligible trials into three types – acupuncture compared to no intervention, acupuncture compared to standard treatment, and “true” acupuncture compared to “sham” acupuncture.

The results are not difficult to guess. The first two groups showed a benefit from acupuncture. Of course they did – these were unblinded studies. It is already well-established that most symptomatic interventions, acupuncture included, will have a perceived placebo effect, most notably for pain symptoms.

The only comparison any science-based practitioner should care about are the blinded comparisons between true and sham acupuncture, for which the reviewers found:

Fourteen trials compared a ‘true’ acupuncture intervention with a variety of sham interventions. Pooled analyses did not show a statistically significant superiority for true acupuncture for any outcome in any of the time windows, but the results of single trials varied considerably.

Right – no effect when looked at together, with lots of variability in individual trials. This is exactly the pattern we see for treatments that have no real physiological effect.

Now again – imagine a pharmaceutical company going to the FDA with this evidence for their new anti-migraine drug. The unblinded trials show a benefit over doing nothing or standard care. But the blinded placebo-controlled trials show no effect. The FDA would tell them to take a hike.

Amazingly, the Cochrane reviewers concluded:

Available studies suggest that acupuncture is at least as effective as, or possibly more effective than, prophylactic drug treatment, and has fewer adverse effects. Acupuncture should be considered a treatment option for patients willing to undergo this treatment.

This conclusion is simply not justified by the evidence.  This, by the way, is an excellent example of the difference between evidence-based medicine and science-based medicine. SBM considers prior-plausibility, which is low for acupuncture, and also has a greater respect for the vagaries and limitations of clinical trials. EBM, at least as practiced by Cochrane, in my opinion and that of others, puts too much faith in clinical trials.

But even according to Cochrane’s own criteria, this conclusion is not justified. The principles of EBM state that better quality evidence trumps lower quality evidence. With regard to acupuncture and migraine, the best evidence is all negative, while weaker evidence is mixed if overall positive. The best evidence (blinded controlled trials) says that there is no effect from acupuncture for migraine. That should have therefore been the conclusion of reviewers.

Here are two recent well-controlled trials as examples. This one published in the Lancet in 2006 found:

Treatment outcomes for migraine do not differ between patients treated with sham acupuncture, verum acupuncture, or standard therapy.

And this one published in the Clinical Journal of Pain in 2008 found:

Individualized treatment based on traditional Chinese medicine plays a role in preventing migraine attacks. Nevertheless, sham acupuncture had similar effects. Major conclusions were limited by the small sample sizes however the observed trends may contribute to design future trials.

These are the two most recent well-designed controlled trials of acupuncture and migraine – both negative with no statistically significant difference between true acupuncture and sham acupuncture. The only difference is that the authors on the 2008 paper tried to spin the results by saying that the sham acupuncture was also effective. Sorry – you don’t get to conclude that your placebo also worked (also acupuncutre proponents really like this strategy) – no difference between treatment and control means no effect.

When one cuts through the CAM spin and misinformation, the bottom line is this – the evidence shows no difference for migraine outcomes between acupuncture treatments and sham acupuncture. It’s an elaborate placebo.  There is therefore no reason to think that acupuncture has any specific role to play in migraine therapy.

Unfortunately CAM proponents have been successful in controlling the reigns of journal, academic position, and even EBM reviews of their own claims, and muscling out those pesky skeptics. They are not alone – the pharmaceutical industry tries to do this also. Recently Merck has been criticized for paying for the publication of a fake journal, made to look as if it were a legitimate peer-reviewed journal, but used to market Merck products. This is unacceptable behavior and a threat to SBM.

SBM depends upon independent science and medical academia. We are right to be vigilant against corporate intrusion into academia, and recent reforms in this area are welcome. But CAM proponents do the exact same things that they criticize in “Big Pharma.” They create newsletters and journals that are little more than marketing tools for their products and services. They infiltrate academia with big donations, trying to control the academic medical agenda and insulate their claims from skeptical scrutiny.

Science and academia have yet to fully wake up to this threat. While much deserved attention is being paid to pharmaceutical company shenannigans, CAM proponents have so far gotten a free ride.

The risk at present is that the big push for health care reform will be hijacked by those with an ideological or even corporate (although CAM corporate) agenda. Our only defense is that Obama will truly listen to the science and to scientists. Unfortunately, CAM science has already been tainted by narrow interests and ideology. The process at present is broken, and I don’t think many people realize it. Therefore Obama and his administration and likely to get misinformation when it comes to CAM, like he did with regard to acupuncture and migraines.

I am not optimistic about how this will play out.

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17 responses so far

17 Responses to “Obama’s Health Initiative – Acupuncture for Migraine”

  1. freddieon 07 May 2009 at 1:32 pm

    So who is taking up the charge to lobby the congress and the Obama administration on how scientific study of medicine SHOULD influence health care?

    Who’s on the front lines? And are there ways to get onto the major news networks and radio to help coordinate a push towards educating the public and the politicians about the importance of this era of transition and progressive revision of our policies?

    It’s great to identify the problem, and to try to explain the specifics of the claim Obama made, but I’m wondering where the front lines on this are and who’s working on it to make blog posts like this part of a larger effort and not just an isolated post.

  2. artfulDon 07 May 2009 at 3:06 pm

    Acupuncture works in Indonesia.

  3. TimKon 07 May 2009 at 3:31 pm

    I’m also interested in the President’s claim that “we will save huge amounts of money” by increasing spending on prevention. Maybe, but maybe not. I bet the country could save health care dollars by eliminating spending on anti-smoking initiatives and letting more people die decades early from lung cancer. It’s conceivable that the cost of public health interventions and regulations aimed at managing children’s diet (plus the additional costs of caring for them when they live longer) would be more than the cost of managing the consequences of obesity.

    I am of course not advocating against prevention measures, but I think we should be skeptical of unqualified claims that increased spending on preventative care will lead to less health care spending overall. Maybe it does sometimes, but not necessarily. A more careful framing of prevention is as an investment in human health: it costs more in health care dollars than the status quo, but we get more happiness and productivity in return.

  4. TimKon 07 May 2009 at 3:35 pm

    re-reading the quote, I think Obama was a bit more cautious and nuanced than my prior comment gives him credit for. all the more disappointing that he threw a bone to the acupuncturist lobby…

  5. weingon 07 May 2009 at 4:10 pm

    “I bet the country could save health care dollars by eliminating spending on anti-smoking initiatives and letting more people die decades early from lung cancer.”

    They could also make money from all the cigarette taxes by demanding everyone buy a pack of cigarettes a day. I hear they are doing something similar in China already.

  6. superdaveon 07 May 2009 at 5:53 pm

    While I am 100% for helping the healthcare system anyway we can in order to help save lives and give Americans healthier lives, I think that cost is a dubious selling point. For one thing, it might not be true, for another, cost should be no object when considering the importance of this goal.

  7. wertyson 07 May 2009 at 8:42 pm

    As Steve says,

    For it to be cost effective, it still has to be effective. Otherwise it’s just diversion from effective treatment.

  8. Esattezzaon 07 May 2009 at 9:00 pm

    Some relevant information from a ScienceDebate2008 mailing list email:

    Barack Obama pledged to Science Debate that he would “restore the science integrity of government and restore transparency of decision-making…” He has referred to this pledge several times since, most recently in his speech to the National Academies of Science. On March 9, the president formally asked the White House Office of Science and Technology Policy (OSTP) to make recommendations on how the executive branch can meet this pledge.

    The OSTP has opened a public comment period regarding this directive, giving you the opportunity to share your thoughts on what the next steps should be. Comments are due by Wednesday, May 13.

    The OSTP is looking for recommendations on the six issues President Obama identified in his memo:

    hiring and keeping qualified scientists
    defining new policies to ensure integrity
    using “well-established scientific processes” like peer review
    disclosing scientific findings
    ensuring that principles of scientific integrity are being adhered to
    adopting additional policies like whistleblower protections

    The OSTP is accepting comments via email and through their blog.

  9. empiricalgod2on 07 May 2009 at 11:12 pm

    Thanks for that # Esattezza

  10. eiskrystalon 08 May 2009 at 3:29 am

    I would ask why our health must be cost effective.

    Generally good speech, very politician-like.

  11. kvsherryon 08 May 2009 at 1:05 pm

    What it looks like Obama did was the old trick of rephrasing the question back to the guy. He was asked “…knowing that the National Institutes of Health and the World Health Organization has discovered through their studies that alternative medicine often is more cost-effective and very effective…” would CAM have a place?

    The first part of his answer just automatically assumes the premise of the question. This is where he went wrong. One word could have fixed this. “IF”…So I think IF it is pretty well documented…That would have placated the questioner (a politicians job) and not made him sound like he was endorsing accupuncture or speaking with knowledge of the subject.

  12. gavinoon 08 May 2009 at 4:44 pm

    I wrote about my dismay over my congressperson’s support for the Federal Acupuncture Coverage Act of 2009 on Tuesday on my blog. Bottom line for me:

    Maybe acupuncture is the most effective-for-the-money treatment for (say) lower back pain for people who really, truly believe that thousands of years of traditional Chinese medicine can’t possibly be wrong. I think they should be free to spend money on whatever treatment works best (or whatever treatment they think works best) for them, but we need a health care system that exposes them to the costs of their decisions; when faced with a decision between paying $100 for a visit to an acupuncturist or spending $10 for a bottle of pain pills, they might decide that the needles aren’t such a good idea after all.

  13. tmac57on 08 May 2009 at 6:22 pm

    Re:Esattezza’s post ,the link to the OSTP Blog site is: http://blog.ostp.gov/
    There aren’t as many comments as I would have expected, so if some of you interested scientists or others want your voices heard on these issues, now is your chance. It’s easy to complain after the fact, but it’s better to speak out when you have a chance.

  14. Esattezzaon 08 May 2009 at 11:40 pm

    Thanks tmac, I hadn’t realized the links did not remain in the post from the original email.

  15. sonicon 11 May 2009 at 7:07 am

    The conclusion that acupuncture does not work does not coincide with the evidence presented.

    From the 2009 Cocrane review:

    “Four trials compared acupuncture to proven prophylactic drug treatment. Overall in these trials acupuncture was associated with slightly better outcomes and fewer adverse effects than prophylactic drug treatment.”

    This implies that acupuncture is a safe and effective treatment compared to the “proven” prophylactic drug treatment.

    A drug company could go to the FDA with a study that showed their treatment to be better than the existing proven treatment and get approval based on that fact.

    The conclusion that it is possible that the exact placement of the needles may not be as important as thought, does not invalidate the therapy.

    Just because there might be a mistake in exactly how something works does not invalidate that it does work. The studies quoted would indicate that acupuncture works as well as or better than any other current therapy.

    There is nothing in the evidence to indicate that the therapy did not work better than any existing therapy and better than doing nothing.

    The fact that something works better than the proven therapy means that it works.

    To conclude otherwise is to misread the evidence as presented.

  16. snazzy1on 12 May 2009 at 12:10 am

    I am not a believer in acupuncture but according to the news sham acupuncture works just as good as real acupuncture and both work better than conventional therapy. Today is May11, 2009 just look at the news today from the L.A Times to Reuters, so what gives???

  17. snazzy1on 12 May 2009 at 12:16 am

    Sorry, didn’t include link to the study here;
    http://archinte.ama-assn.org/cgi/content/abstract/169/9/858?lookupType=volpage&vol=169&fp=858&view=short

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