Revisited: Snake oil

The letter from Dr Bell, et al. in the July/August edition of the BCMJ (2006;48[6]:255-256) contains some important misconceptions that require urgent rebuttal.

Dr Bell states that there is a “considerable volume of high-quality research” that supports the effectiveness of complementary and alternative medicine (CAM). In point of fact, this is true. The problem is that there is a far greater quantity of even higher-quality evidence that tells the opposite story. A case in point is homeopathy, invoked by Dr Bell as an example of a scientifically sound practice. Those physicians who recall high school chemistry will be interested to note that a typical homeopathic remedy is diluted vastly beyond the point where a single atom of the allegedly active substance could be present (so much so that one would have to consume a sphere many kilometres in diameter to get even a single atom). Furthermore, even though one can find positive trials of homeopathy in the published literature, the best quality trials are overwhelmingly negative and we have yet to see consistent positive RCTs conducted by non-proponents.[1,2] Under such circumstances, one might wonder if disciples of homeopathy are concerned about scientific quality or are simply suffering from “dilutions of grandeur.”

Why Dr Bell presents acupuncture as the other CAM poster child is somewhat puzzling. To be sure, most of the over 800 clinical trials of acupuncture have declared it to be positive, yet systematic reviews that have taken the quality of the trials into account have found that the alleged effects are almost universally illusory, particularly when sham acupuncture is used as a control.[3-29] As more research is being done, the number of diseases for which acupuncture seems to be promising appears to be shrinking. To date, it appears that the only conditions for which acupuncture enjoys anything near consistent positive RCTs are post-operative nausea and vomiting and some (oddly, not all) types of musculoskeletal pain,[10,30-32] and even these trials are fraught with heterogeneity. Critical thinkers, however, will recognize that it really would be remarkable if a treatment used for thousands of years and touted as a cure-all were only good for a couple of conditions, some of which didn’t even exist when the therapy was invented.

The authors also assert that the public is “choosing CAM in droves.” It is worth noting that CAM encompasses a huge array of practices that range from the bizarre to the somewhat plausible but unproven. The studies that have measured public use of CAM (e.g., Eisenberg et al.[33]) have typically included items such as prayer, self-help groups, meditation, and lifestyle change as CAM modalities. Small wonder then that such surveys might indicate that many citizens have used at least one form of CAM in their lifetime.

Dr Bell rightly criticizes the undue influence of vested interests on medical information. But the solution to this problem isn’t to turn back the clock on standards of safety and effectiveness. The solution is to continue to demand higher standards of validity, transparency, and disclosure in the conduct of clinical trials so that we reduce bias in our estimates of the value of medical therapies.

The authors call for open-mindedness with respect to CAM and link this to patient-centred care. One can only hope that Dr Bell is not confusing open-mindedness with gullibility. Modern medicine has been very quick to adopt any therapy proven beneficial. Open-mindedness doesn’t mean low standards of evidence, and it is a problem when unproven ideas are promoted as bona fide therapies, and it is particularly worrisome when practitioners continue to promulgate misconceptions that have long been debunked.

—Lloyd Oppel, MD
Chair, Alternative Health and Therapeutics Committee, COHP


Dr Bell and colleagues’ letter was in response to an article by Dr James E. Miles published earlier in the year. Sadly, Dr Miles died in November, but he would have been pleased to see the debate he started continue on in the pages of the journal to which he was a friend and frequent contributor. We will miss his strong opinions and dry, irreverent humor.—Ed


1. [No authors listed]. The end of homoeopathy. Lancet 2005;366:690. PubMed Citation Full Text 
2. Shang A, et al. Are the clinical effects of homoeopathy placebo effects? Comparative study of placebo-controlled trials of homoeopathy and allopathy. Lancet 2005;366:726-732. PubMed Abstract Full Text 
3. Ferrandez Infante A, et al. Effectiveness of acupuncture in the treatment of pain from osteoarthritis of the knee. Aten Primaria 2002;30:602-608; 609-610. PubMed Abstract Full Text 
4. Gates S, Smith LA, Foxcroft DR. Auricular acupuncture for cocaine dependence. Cochrane Database Syst Rev 2006;1:CD005192. PubMed Abstract Full Text 
5. Leo RJ, Ligot JS, Jr. A systematic review of randomized controlled trials of acupuncture in the treatment of depression. J Affect Disord 2006 Aug 7 [E pub ahead of print]. PubMed Abstract Full Text 
6. Lee A, et al. Publication bias affected the estimate of postoperative nausea in an acupoint stimulation systematic review. J Clin Epidemiol 2006;59:980-983. PubMed Abstract Full Text 
7. Wu HM, et al. Acupuncture for stroke rehabilitation. Cochrane Database Syst Rev 2006;3:CD004131. PubMed Abstract Full Text 
8. Griggs C, Jensen J. Effectiveness of acupuncture for migraine: Critical literature review. J Adv Nurs 2006;54:491-501. PubMed Abstract Full Text 
9. Cheuk DK, Wong V. Acupuncture for epilepsy. Cochrane Database Syst Rev 2006;2:CD005062. PubMed Abstract Full Text 
10. Ezzo JM, et al. Acupuncture-point stimulation for chemotherapy-induced nausea or vomiting. Cochrane Database Syst Rev 2006;2:CD002285. PubMed Abstract Full Text 
11. White AR, Rampes H, Campbell JL, Acupuncture and related interventions for smoking cessation. Cochrane Database Syst Rev 2006;1:CD000009. PubMed Abstract Full Text 
12. Rathbone J, Xia J. Acupuncture for schizophrenia. Cochrane Database Syst Rev 2005;4:CD005475. PubMed Abstract Full Text 
13. Casimiro L, et al. Acupuncture and electroacupuncture for the treatment of rheumatoid arthritis. Cochrane Database Syst Rev 2005;4:CD003788. PubMed Abstract Full Text 
14. Jedel E. Acupuncture in xerostomia—a systematic review. J Oral Rehabil 2005;32:392-396. PubMed Abstract Full Text 
15. Green S, Buchbinder R, Hetrick S. Acupuncture for shoulder pain. Cochrane Database Syst Rev 2005;2:CD005319. PubMed Abstract Full Text 
16. Smith CA, Hay PP. Acupuncture for depression. Cochrane Database Syst Rev 2005;2:CD004046. PubMed Abstract Full Text 
17. Zhang SH, et al. Acupuncture for acute stroke. Cochrane Database Syst Rev 2005;2:CD003317. PubMed Abstract Full Text 
18. Manheimer E, et al. Meta-analysis: Acupuncture for low back pain. Ann Intern Med 2005;142:651-663. PubMed Abstract Full Text 
19. Furlan AD, et al. Acupuncture and dry-needling for low back pain: An updated systematic review within the framework of the cochrane collaboration. Spine 2005;30:944-963. PubMed Abstract Full Text 
20. Schoonman GG, Wiendels NJ, Ferrari MD. Still no proof of the efficacy of acupuncture in the prevention of migraine. Ned Tijdschr Geneeskd 2004;148:2165-2166. PubMed Abstract 
21. McCarney RW, et al. An overview of two Cochrane systematic reviews of complementary treatments for chronic asthma: Acupuncture and homeopathy. Respir Med 2004;98:687-696. PubMed Abstract 
22. McCarney RW, et al. Acupuncture for chronic asthma. Cochrane Database Syst Rev 2004;1:CD000008. PubMed Abstract Full Text 
23. Cherkin DC, et al., A review of the evidence for the effectiveness, safety, and cost of acupuncture, massage therapy, and spinal manipulation for back pain. Ann Intern Med 2003;138:898-906. PubMed Abstract Full Text 
24. Sze FK, et al. Does acupuncture improve motor recovery after stroke? A meta-analysis of randomized controlled trials. Stroke 2002;33:2604-2619. PubMed Abstract Full Text 
25. Green S, et al. Acupuncture for lateral elbow pain. Cochrane Database Syst Rev 2002;1:CD003527. PubMed Abstract 
26. Park J. et al. Effectiveness of acupuncture for stroke: A systematic review. J Neurol 2001;248:558-563. PubMed Abstract Full Text 
27. Melchart D, et al. Acupuncture for idiopathic headache. Cochrane Database Syst Rev 2001;1:CD001218. PubMed Abstract 
28. Tulder MV, et al. Acupuncture for low back pain. Cochrane Database Syst Rev 2000;2:CD001351. PubMed Abstract 
29. van Tulder MW, et al. The effectiveness of acupuncture in the management of acute and chronic low back pain. A systematic review within the framework of the Cochrane Collaboration Back Review Group. Spine 1999;24:1113-1123. Full Text 
30. Ezzo J, Streitberger K, Schneider A. Cochrane systematic reviews examine P6 acupuncture-point stimulation for nausea and vomiting. J Altern Complement Med 2006;12:489-495. PubMed Abstract Full Text 
31. Kwon YD, Pittler MH, Ernst E. Acupuncture for peripheral joint osteoarthritis: A systematic review and meta-analysis. Rheumatology (Oxford) 2006; 45:1331-1337. PubMed Abstract Full Text 
32. Trinh KV, et al. Acupuncture for the alleviation of lateral epicondyle pain: A systematic review. Rheumatology (Oxford) 2004;43:1085-1090. PubMed Abstract Full Text 
33. Eisenberg DM, et al. Trends in alternative medicine use in the United States, 1990-1997: Results of a follow-up national survey. JAMA 1998;280:1569-1575. PubMed Abstract Full Text 

Lloyd Oppel, MD, MHSc, FCFP(Em). Revisited: Snake oil. BCMJ, Vol. 48, No. 10, December, 2006, Page(s) 495-499 - Letters.

Above is the information needed to cite this article in your paper or presentation. The International Committee of Medical Journal Editors (ICMJE) recommends the following citation style, which is the now nearly universally accepted citation style for scientific papers:
Halpern SD, Ubel PA, Caplan AL, Marion DW, Palmer AM, Schiding JK, et al. Solid-organ transplantation in HIV-infected patients. N Engl J Med. 2002;347:284-7.

About the ICMJE and citation styles

The ICMJE is small group of editors of general medical journals who first met informally in Vancouver, British Columbia, in 1978 to establish guidelines for the format of manuscripts submitted to their journals. The group became known as the Vancouver Group. Its requirements for manuscripts, including formats for bibliographic references developed by the U.S. National Library of Medicine (NLM), were first published in 1979. The Vancouver Group expanded and evolved into the International Committee of Medical Journal Editors (ICMJE), which meets annually. The ICMJE created the Recommendations for the Conduct, Reporting, Editing, and Publication of Scholarly Work in Medical Journals to help authors and editors create and distribute accurate, clear, easily accessible reports of biomedical studies.

An alternate version of ICMJE style is to additionally list the month an issue number, but since most journals use continuous pagination, the shorter form provides sufficient information to locate the reference. The NLM now lists all authors.

BCMJ standard citation style is a slight modification of the ICMJE/NLM style, as follows:

  • Only the first three authors are listed, followed by "et al."
  • There is no period after the journal name.
  • Page numbers are not abbreviated.

For more information on the ICMJE Recommendations for the Conduct, Reporting, Editing, and Publication of Scholarly Work in Medical Journals, visit

BCMJ Guidelines for Authors

Leave a Reply