Leave it to integrative medicine advocates. No sooner do I discuss how they are co-opting the opioid crisis as a “rationale” for integrating quackery into medicine for the treatment of chronic pain than they serve up another example of just that tendency. I saw this example where I see a lot of examples of this sort of thing, on Twitter:
The Academic Consortium for Integrative Medicine’s @imconsortium white paper on #EvidenceBased #NonDrug approaches to pain is now available here: https://t.co/QDsiAdzEUO @Integrativeonc @IntegratCancer @DukeIM @IHITeam @integrativeonco
— Dr. Linda E. Carlson (@Linda_E_Carlson) January 23, 2018
OK, it was almost a week ago, but I usually only post on SBM once a week. In any event, what we have here is an example of one of the most powerful forces promoting the “integration” of pseudoscience and quackery into medicine continuing to do so by, yes, taking advantage of the opioid crisis to present its unscientific, pseudoscientific, and mystical prescribed solutions to the crisis.
The Academic Consortium for Integrative Medicine and Health: Promoting quackademic medicine for two decades
What Dr. Carlson was referring to in her Tweet was the Academic Consortium for Integrative Medicine and Health (formerly, The Consortium for Academic Health Centers for Integrative Medicine). The ACIMH, if you’ll recall, has been discussed on this very blog several times for its role in promoting quackademic medicine over the years. Consisting of roughly 70 academic medical centers in North America, the ACIMH declares its mission to be to “advance integrative medicine and health through academic institutions and health systems.
That’s exactly what it does, too. Unfortunately, it’s been wildly successful, having started out with eight founding members and expanded its membership many-fold over the last two decades. Among its members (and beyond), for instance, Jann Bellamy noted that the ACIMH has been promoting the establishment of integrative medicine programs in academic health centers. While the authors, of one of the papers that she discussed, including our old friend Ted Kaptchuk, discussed the barriers to starting such programs, Jann was, as she should be, more concerned with the infiltration of pseudoscience into the residency curriculum than with how to “integrate” terminology related to pseudomedicine such chiropractic, acupuncture and traditional Chinese medicine into the electronic health record, which was one of main concerns of the article she discussed. Indeed, the ACIMH also likes to promote “partnerships” between quack schools like the naturopathic Bastyr University, and real medical schools, like Georgetown.
Of course, whenever I criticize this infiltration, there are people and forces who are displeased. I very frequently encounter pushback. Often this pushback comes from John Weeks, an early cheerleader for “complementary and alternative medicine” (CAM) and later the rebranding of CAM known as “integrative medicine” who is now editor of the Journal of Alternative and Complementary Medicine, even though at the time he was hired he had no relevant experience editing an academic journal and wasn’t even a physician or a scientist. Now he spends his time accusing CAM critics of “polarization-based medicine” and compared to Donald Trump. Although the ACIMH is not the only force promoting the infiltration of quackery into medical academia, with the Bravewell Consortium and the Samueli Institute both having closed, it is arguably the most influential such organization remaining, along with the University of California, Irvine, where Susan and Henry Samueli donated $200 million to promote integrative medicine.
The ACIMH takes advantage of the opioid epidemic
Recently, the ACIMH published its Moving Beyond Medications guidelines. The express purpose is, as was the National Center for Complementary and Integrative Health’s latest strategic plan, to rebrand “nonpharmacologic treatments for pain” as being all “integrative” or “CAM.” The other part of this rebranding is that potentially science- and evidence-based interventions for pain, such as exercise, are mixed—or, dare I say it, integrated—with quackery, like chiropractic and acupuncture. This is accomplished through a white paper, a series of guides, and a series of one- or two-page evidence summaries.
For instance, here is the pocket guide. It lists five steps to treating pain. None of the steps are objectionable on the surface:
- Assess the patient’s pain and well-being
- Set goals jointly with the patient
- Educate the patient about pain management options
- Develop a treatment plan with the patient; address potential challenges
- Followup, troubleshoot, and modify treatment plan as needed
I can’t think of any physician I know who would object to these steps. The devil, of course, is in the details. For instance, under #3, we see:
Describe evidence-informed non-pharmacological and self-care approaches to managing pain and promoting wellness, including but not limited to:
- Chiropractic, Osteopathic and Myofascial Manipulation, Massage Therapy, and
- Physical Therapy
- Cognitive Behavioral Therapy, Stress Management, and other psychological therapies
- Mind-Body Approaches, Meditation, Biofeedback, Guided Imagery
- Yoga, Tai Chi, and other movement therapies
See what I mean? Potentially evidence-based treatments, such a physical therapy, cognitive behavioral therapy, stress management, and the like, are included in a list with acupuncture (which is no more than a theatrical placebo), chiropractic (chiropractors are, as I like to say, improperly trained physical therapists with delusions of grandeur); and osteopathic and myofascial manipulation.
There are a total of four evidence summaries for the treatment of pain devoted to acupuncture alone, Acupuncture Cancer Pain, Acupuncture Chronic Pain, Acupuncture Post-Op Pain Opioid Sparing, Acupuncture Therapy Acute Pain. Perusing this evidence summary, which presumably is the best that the ACIMH could come up with, given its mission to promote integrative medicine, I was amazed at how weak and equivocal even the “best” studies were.
For instance, here’s a quote from a systematic review by the American Society of Clinical Oncology (ASCO):
The American Society of Clinical Oncology Clinical Practice Guidelines found acupuncture and massage were effective in improving pain. The reviewers categorized these findings as ‘evidence-based; benefits outweigh harms; evidence quality: low; strength of recommendation: weak’.
Here’s a quote from a review:
A review on the management of peripheral neuropathy induced by chemotherapy found acupuncture among therapies that may be useful for PN, but not electroacupuncture.
Not exactly ringing endorsement, is it? What about acupuncture for chronic pain? It’s not much better. Not surprisingly, there’s this right at the top of the list:
The 2017 Clinical Guidelines of the American College of Physicians recommend that for acute, subacute and chronic low back pain, clinicians and patients should select nonpharmacologic treatments as a first line of care with acupuncture therapy included as one option.
I can’t help but note that the inclusion of acupuncture in the 2017 ACP Clinical Guidelines was based on incredibly thin evidence. I couldn’t help but note the questionable nature of the actual studies used to justify the recommendations. For example, this study showed that there was no difference between “true” acupuncture and sham acupuncture (which is what pretty much all well-designed acupuncture studies show). In other words, it showed that acupuncture is a placebo intervention. This study tested a sort of “scalp acupuncture” that I’ve never heard of before. Another study was from China, and, as has been discussed before, pretty much all acupuncture studies out of China are positive. The authors actually included the GERAC study in its list, which basically showed that acupuncture does not work, given that sham acupuncture was indistinguishable from acupuncture. Another study was a “bait and switch” in that it studied “electroacupuncture,” which is in reality transcutaneous nerve stimulation (TENS). We’re talking thin gruel indeed here.
Then, of course, ACIMH couldn’t help but quote the NCCIH review of integrative medicine for pain:
The National Institutes of Health (NIH) National Center for Complementary and Integrative Health (NCCIH) reviewed evidence-based approaches for pain management and recommended acupuncture and yoga for low back pain; and acupuncture and Tai chi for knee osteoarthritis
I discussed this review in detail right here on this very blog when it was first published nearly a year and a half ago. It was one of the times I pointed out the strategy integrative medicine advocates are using, noting the careful framing. Basically, integrative medicine advocates co-opt the sensible, the science-based, and the potentially science-based lifestyle interventions for pain as being “complementary” or “integrative,” thus claiming them for their own. They also divide interventions for pain into two categories, “pharmacological” and “non-pharmacological.” Guess which one they claim for their own as being “CAM” or “integrative”? At the same time, they further the stereotype that science- and evidence-based medicine is all about nothing more than drug therapy.
Then, of course, there’s the Vickers meta-analysis from 2012:
A 2012 individual patient data meta-analysis of acupuncture for four chronic pain conditions: back and neck pain, osteoarthritis, chronic headache, and shoulder pain found acupuncture is effective beyond placebo effect and is a reasonable referral options.
I can’t help but note that this particular meta-analysis has been discussed many times by myself and skeptical bloggers, including by Steve Novella, Mark Crislip, and myself. (The author of the meta-analysis was not pleased.) It’s one of the most widely cited acupuncture studies used to argue that acupuncture works, but it actually doesn’t show anything of the sort. At best, it shows that if there is a difference in pain perception in patients due to acupuncture it’s statistically significant but clinically insignificant.
Of course, the two main problems with the vast majority of acupuncture trials is that they are rarely double blind and, even when they are, the sham acupuncture control is usually inadequate. There’s a reason why, if you look at the totality of the literature, as the scientific rigor of an acupuncture clinical trial increases, the effect size decreases, to the point that the very best trials generally show at best a clinically insignificant effect and in general no effect distinguishable from placebo. This is not surprising, given that, as I mentioned before, acupuncture is a theatrical placebo. Add to all this unimpressive data the extreme biological implausibility of acupuncture, and, using a Bayesian approach taking into account pretest probability based on biological plausibility, one can only conclude that the evidence for acupuncture as a treatment for pain (or anything, for that matter) is negative.
Enter the AHRQ
The US Agency for Healthcare Research and Quality (AHRQ) is an agency in the US Department of Health and Human Services that was established in 1989 as the Agency for Health Care Policy and Research (AHCPR) with a mission to enhance the quality, appropriateness, and effectiveness of health care services and access to care by conducting and supporting research, demonstration projects, and evaluations; developing guidelines; and disseminating information on health care services and delivery systems. The AHRQ’s key areas of focus are:
- Safety and Quality: Reduce the risk of harm by promoting delivery of the best possible care.
- Effectiveness: Improve health care outcomes by encouraging the use of evidence to make informed health care decisions.
- Efficiency: Transform research into practice to facilitate wider access to effective health care service and reduce unnecessary costs.
One important function of AHRQ is to fund comparative effectiveness research, which compares existing approved treatment modalities for effectiveness, safety, and cost, in order to determine which ones are preferable to use in which patients. The ACIMH states in its report:
The Consortium and other pain experts have provided comments as part of the AHRQ call for predissemination peer review of this document. The draft document is posted here as a resource to provide a comparative effectiveness review of the evidence on noninvasive, nonpharmacological treatments for common chronic pain conditions, focusing on whether improvements are seen for at least one month post-intervention. While this results in not including some studies, by doing so it focuses on more sustainable benefits of nonpharmacological approaches.
The document to which the ACIMH is referring is the Draft Comparative Effectiveness Review for Noninvasive, Nonpharmacological Treatment for Chronic Pain: A Systematic Review. The draft review notes that it has not been officially disseminated by the AHRQ yet, but has been distributed solely for the purposes of predissemination peer review. Given the power of the AHRQ, I am betting that, whatever the AHRQ concludes, the final systematic review’s findings will be a Big Deal and potentially a propaganda goldmine for advocates of integrative medicine.
So let’s take a look.
The review examines the evidence for non-pharmacological treatments for five common chronic pain conditions (low back pain, neck pain, osteoarthritis of the knee, hip or hand, fibromyalgia, and tension headache), addressing efficacy or harms compared with usual care, no treatment, waitlist, placebo, or sham intervention; compared with pharmacological therapy; or compared with exercise. The quality of included studies was assessed, data were extracted, and results were summarized.
The first thing that I noticed perusing all these conditions and interventions is that there is not a single condition paired with an intervention for which the AHRQ judged the strength of evidence (SOE) as “high.” At best, there was “moderate” SOE, and the vast majority of the SOE appraisals fell into the category of “low.” Let’s look at what the draft review says about acupuncture for low back pain as far as standardized mean difference (SMD) and other parameters:
- Acupuncture was associated with slightly greater effects on short-term function than sham acupuncture or usual care (4 trials, pooled SMD -0.22, 95% CI -0.35 to -0.08, I2=44%). There were no differences between acupuncture versus controls in intermediate-term function (3 trials, pooled SMD -0.08, 95% CI -0.36 to 0.20, I2=75%) or long-term function (1 trial, adjusted difference -3.4 on the 0 to 100 ODI, 95% CI -7.8 to 1.0) (SOE: Low).
- Acupuncture was associated with slighter greater effects on short-term pain than sham acupuncture, usual care, an attention control, or a placebo intervention (5 trials, pooled difference -0.55 on a 0 to 10 scale, 95% CI -0.86 to -0.24, I2=30%). There was no difference in intermediate-term pain (5 trials, pooled mean difference -0.25, 95% CI -0.67 to 0.16, I2=33%); one trial found acupuncture associated with greater effects on long-term pain (mean difference -0.83, 95% CI -1.51 to -0.15) (SOE: Moderate for short-term, low for intermediate-term and long-term).
Again, this is very thin gruel, the very essence of finding small differences that are statistically significant but almost certainly clinically insignificant. A difference of 0.55 on a visual pain scale from 0-10 is almost certainly below a threshold known as the “minimally clinically important difference” (MCID), defined as “the smallest difference in score in the domain of interest which patients perceive as beneficial and which would mandate…a change in the patient’s management.”
I could go on, but for the most part these are the sorts of results one finds for acupuncture. The results are somewhat better for some of the other modalities, such as exercise, physical therapy, multidisciplinary rehabilitation, and mindfulness-based stress reduction, although in the vast majority of cases the SOE was low, with a few examples of moderate SOE.
Maybe this report won’t be that big a bombshell after all.
The rebranding continues
The ACIMH’s Moving Beyond Medications initiative concludes with a plug for its upcoming conference in May in Baltimore. Although the website doesn’t yet show the program schedule, we do learn that major speakers will include Tracy W. Gaudet, MD, Executive Director of the Veterans Health Administration’s National Office of Patient Centered Care & Cultural Transformation. We’ve met her before in her role as being a key driving force behind the introduction of naturopathic quackery and acupuncture into the VA Medical System. Then there’s Helene Langevin, MD, who serves as Director, Osher Center for Integrative Medicine at Brigham and Women’s Hospital & Harvard Medical School. She’s best known for having claimed to have matched real anatomical structures with the elusive acupuncture “meridians.” When last I encountered her, she was still at the University of Vermont, but here I learn she’s moved up in the world.
Never forget that the real purpose of integrative medicine, whether acknowledged or not, whether even admitted to themselves by advocates or not, is to integrate quackery with medicine. Rebranding their nostrums as “nonpharmacologic” treatments for pain serves two purposes. First, it allows integrative medicine to claim certain science-based modalities, such as diet, exercise, and evidence-based physical therapy, as solely belonging in their bailiwick. Second, it allows them to give a false sense of scientific legitimacy to the pseudoscience, such as acupuncture, energy medicine, and the like into the treatments they’re so desperately trying to “integrate” into medicine. Finally, these two tactics allow integrative medicine advocates to claim all nonpharmacological treatments of pain as their own, separate from science- and evidence-based medicine, even when such treatments have existed in that realm for a long time.
That’s what the ACIMH report on nonpharmacological treatments for pain is all about.