evidence for acupuncture

Guest blog article by acupuncturist Mel Hopper Koppelman

evidence for acupuncture

 

Disclaimer: I am an acupuncturist and this article has a pro-acupuncture leaning. Phew, now that we got that out of the way . . .

Over the last few decades, acupuncture has gone mainstream in the West. With a growing evidence-base, a sparkling safety profile, and a demonstrated track record of effectiveness, medical professionals are increasingly recommending it and patients are increasingly choosing it for relief and results.

But in the words of Chris Brown: “Haters keep on hating, cause somebody’s gotta do it.” And with this, I have no problem. I certainly don’t expect everyone to love acupuncture or even to try it. It’s merely a good treatment option for certain patients, many times better than what conventional medicine can offer.

However the specific anti-acupuncture arguments I hear repeated do have certain flaws; they are based on poor reading and interpretation of the literature, and in some cases they are based on pure fantasy. So with that in mind, I shall address the three most common arguments in the anti-acupuncture arsenal: it’s a placebo, it’s dangerous, and it isn’t evidence based.

It’s just placebo

Attributing acupuncture’s beneficial effects down to placebo is a very common argument made by critics. However, it needs to be pointed out that this criticism doesn’t address whether or not acupuncture works; rather, it’s one possible explanation as to how it works, or the mechanism behind its effectiveness. Indeed, saying that acupuncture is “just a placebo” is to acknowledge that it is indeed effective. I would argue that if you are trying to find effective treatments for patients the more relevant question is, for a particular condition or symptom, how does it compare to the standard treatment?

Let’s take acupuncture in the treatment of migraines, for example. The most recent Cochrane Review of acupuncture for the treatment of migraines concludes that while there does not seem to be a significant difference in effect size between acupuncture and placebo acupuncture, both are more effective than prophylactic pharmaceuticals with fewer side effects.1

So, let’s break this down. Prophylactic drugs have been demonstrated to be more effective for preventing migraines than placebo treatment in the form of a sugar pill.2 And both true acupuncture and fake acupuncture are more effective than the drug, which in itself exerts a placebo effect in addition to the known pharmacological action.

Critics use these results as evidence that acupuncture doesn’t really work and that it’s all in the mind. But what these results actually show is that even if acupuncture is a placebo, it works better than conventional treatment. I say that if acupuncture can exert a placebo effect greater than the combined effect of placebo and biological action of a drug, we really need to be a bit humble about what we think we know about the human body. Based on this research, if I or someone that I cared about had a migraine, I know which treatment I would choose.

Personally, I agree with Simon Singh and Edzard Ernst’s take here: “Demonstrating that a treatment is effective is the number-one priority in medicine; understanding the exact details of the underlying mechanism can be left as a problem for subsequent research.” 3

But is acupuncture just a placebo?

In many randomised placebo-controlled trials, acupuncture performs equally well to the placebo control for certain conditions whereas for other conditions it is significantly more effective. But unlike drug trials that can use sugar pills as a convincing biologically-inert placebo control, testing complex interventions like acupuncture is more challenging and different strategies have been used over the years. So when looking at a “placebo controlled” trial of acupuncture, the first question to ask is what exactly were they using as a placebo control?

Sham acupuncture, which is either the insertion of needles in non-acupuncture points or acupuncture needles that have been inserted shallowly, is often used for this purpose. However, many have argued and I would echo that this is merely a different type of acupuncture and not a true placebo control as it is not biologically inert. “Non-penetrating shams,” which are treatments where the acupuncture needle isn’t actually inserted at all, are a better choice.

We know that placebo interventions can be effective and that acupuncture has been shown to be effective, too. So the question is: is acupuncture just acting as a placebo by creating a positive expectation for beneficial results or does acupuncture have a measurable mode of action that is distinct from expectation? It turns out that a number of researchers have looked into this question and note some compelling differences:

  • Acupuncture stimulates different areas of the brain from placebo acupuncture
  • Acupuncture has strong effects on opioid receptor binding in the brain in both the short- and long-term whereas sham acupuncture only has a small effect that is similar to traditionally used placebos
  • Acupuncture stimulates significant differences in daily cortisol secretion and heart rate variability as compared to placebo acupuncture 4

So while a growing body of research supports the conclusion that both acupuncture and placebo acupuncture are more effective at treating a number of conditions than standard medical treatment, research into acupuncture’s mechanism of action using brain scanning and various biomarkers demonstrates that the way it works is distinct from expectation.

But, It’s Dangerous

All of the scholarly critiques of acupuncture that I’ve come across say something along the lines of: “If it were just a silly inert placebo, it wouldn’t be so bad. But it’s actually dangerous. I mean, people have actually died.

Let’s Get Number-y

In Do you Believe in Magic?, Dr Paul Offit actually puts a number to acupuncture related mortality: “The final argument against acupuncture is the hardest to refute. Acupuncture needles are not without risk . . . At least eighty-six people have died from acupuncture.”5

Wow, eighty-six is a highly specific number. Soooooo, not to be awkward, but where exactly did this number come from? A reference here would have been helpful. And is that eighty-six people everGlobally? Can I have a denominator please?

Let’s get some perspective. Eighty-six people is the number of preventable deaths that occurred in the United States as a result of medical error every two hours from 2008-2011 6 making it the 3rd leading cause of death after heart disease and cancer.7 Yes, more people use hospitals than acupuncture in the U.S. but that doesn’t come close to touching the difference in death rate.

If acupuncture is dangerous, I really have no idea what to call conventional Western medicine given the current healthcare model. Let me be clear, acupuncture does have some risks, particularly when practiced by non-acupuncturists (duh), but the rate of adverse events overall is extremely low 8, especially when compared to conventional medicine.

It’s ok, I’m an acupuncturist

Ernst and colleagues reveal an interesting trend about acupuncture safety: “Serious complications after acupuncture continue to be reported. Many are not intrinsic to acupuncture, but caused by mal-practice of acupuncturists. This might explain why surveys of adequately trained therapists failed to yield such complications.”9 In other words, acupuncture is dangerous when it’s done wrong. Particularly, by people without adequate training.

I’m going to go ahead and suggest that a whole lot of procedures are dangerous when performed by people without adequate training. Take away point: don’t get acupuncture treatments from your mechanic, your rabbi, your hairdresser, your friendly local barista, your toddler or your pet doberman. Get acupuncture from a properly trained and qualified acupuncturist and then even acupuncture’s staunchest critics agree that it is ridiculously safe.

There’s no scientific evidence that it works

The above criticism is often expressed in various aways (almost always, in my experience, by people who have read nary a research paper on the subject) but the bottom line is, they argue, there’s no scientific evidence to support it. It’s not part of evidence-based medicine. It’s snake-oily voodoo.

The supposition here is that acupuncture is completely unscientific, as diametrically opposed to conventional medicine which is entirely scientific and evidence-based. I think this idea, that pretty much everything that comes under the umbrella of conventional medicine is “evidence-based” and “scientific”, deserves a bit of exploring before heading over to the scientific evidence-base for acupuncture. Let’s look at the following three points:

1) Most conventional treatments are not evidence based

According to the BMJ’s Clinical Evidence, conventional treatments are categorised in the following way when the research literature supporting their use is examined:

  • Beneficial: 11%
  • Likely to be beneficial: 24%
  • Trade-off between benefits and harms: 7%
  • Unlikely to be beneficial: 5%
  • Likely to be ineffective of harmful: 3%
  • Unknown effectiveness: 50%

So a measly 11% of conventional treatments have strong evidence of their effectiveness and safety whereas the vast majority are not evidence-based and some are even known to be harmful.

Ok, so according to the BMJ, most conventional treatments do not actually have a strong scientific evidence-base for their effectiveness. But of the ones that do, how certain can we be that the research is accurate?

15 Nov 2014 Update: It has been brought to my attention that this Clinical Evidence summary is not solely for treatments offered in conventional practice but for any treatments for which enough RCTs have been undertaken. I contacted BMJ Clinical Evidence in an effort to obtain their original data and recalculate the above breakdown to more accurately reflect the evidence-base in conventional practice but they were unable to provide me with this. 

2) Scientific Evidence in General is a bit shaky

According to Professor John Ioannidis’ very well-respected and highly cited article on research methods, most published research findings are actually false.10

Yep, you read that correctly.

For a variety of reasons, including funding sources, poor research design, and good old bog standard bias, most published research findings end up being unrepeatable and/or overturned. And it is on these very results that the entire institution of evidence-based conventional medicine is poised. Shaky foundations, indeed. When your doctor prescribes you a drug or recommends a treatment, assuming that these decisions are even based on the most up to date and highest quality research, there’s a good chance that those conclusions will be shown to be flat out wrong in due course.

Sobering, ain’t it?

3) The Problem with Drug Money

As touched on in the Ioannidis paper, funding source, and not just good old fashioned scientific investigation of reality, significantly affects which conclusions research studies come to. And thus we’re forced to face some unpleasant facts, namely that biomedical research funded by the pharmaceutical industry consistently over-estimates the safety and effectiveness of pharmaceuticals as compared to reality 11 12 and that the majority of biomedical research is funded by the pharmaceutical industry.13 Oh dear.

So, based on the three points above, I’m gonna go ahead and call BS on the whole conventional medicine = evidence-based medicine fantasy.

Does the use of acupuncture have a scientific evidence base?

So in this more realistic context, that some aspects of conventional medicine are evidence-based but most, not so much: is the use of acupuncture supported by scientific evidence?

Before I answer this, a short refresher on what is meant by “strong scientific evidence” in medicine. The “gold standard” of medical research methods is considered to be the Randomised Controlled Trial, which when conducted well greatly reduces the chance that a result is due to something other than treatment effects. A systematic review seeks to identify all such trials for a given treatment, and then objectively summarise the findings. The Cochrane Collaboration is one such organisation that conducts systematic reviews, and their studies are widely accepted as being impartial and of the highest quality.

Singh and Ernst summarise it thusly:

“An evidence-based approach to medicine, as previously discussed, means looking at the scientific evidence from clinical trials and other sources in order to decide best medical practice. The systematic review is often the final stage of evidence-based medicine, whereby a conclusion is drawn from all the available evidence. . . In each case, the wholly independent Cochrane Collaboration presents its conclusions about the effectiveness of whatever is being systematically reviewed. Hopefully this background to the Cochrane Collaboration has helped to convey its reputation for independence, rigour and quality.” 14

A search of Cochrane’s database of systematic reviews returns 95 reviews of acupuncture for a variety of conditions, from various pain conditions to glaucoma to cocaine dependence. Most of these reviews are unable to draw firm conclusions due to a combination of small number of trials done, the poor quality of these trials, and the heterogeneity of the trials.

However, a number of these reviews have found evidence for the efficacy and safety of acupuncture as compared to standard treatment including for migraines, tension type headaches, IBS, fibromyalgia, chronic low-back pain, and various types of nausea. As the quality of acupuncture studies continues to improve, the strength of the evidence continues to grow.

So, yeah, for certain conditions, according to the most rigorous scientific methods available, there is strong scientific evidence for the efficacy of acupuncture.

Acupuncture Improves Many Biomarkers

While the Cochrane reviews are focused on interventions for conditions, a very exciting and vast area of research is the effect of acupuncture in modulating certain biomarkers. It is increasingly understood in conventional medicine that a small number of biochemical mechanisms, like low-level chronic inflammation, underly a very wide number of chronic diseases, from type 2 diabetes to depression to cardiovascular disease to cancer.

Acupuncture has been shown to down-regulate and beneficially effect a host of inflammatory mechanisms including down-regulating the expression of many pro-inflammatory cytokines as well as suppressing COX-1 and COX-2 (like taking an NSAID but without the increased risk of ulcers).15

Acupuncture has also been shown in a number of studies to improve the function of the hypothalamus-pituitary-adrenal axis (HPA-axis), which is basically the physical network through which stress exerts harmful effects on the body.16 This large and growing body of research on acupuncture’s beneficial effects on various fundamental biomarkers helps to explain why it is successfully used for such a wide-variety of clinical conditions.

Parting Thoughts

 

In Trick or Treatment, Singh and Ernst tell us the following: “This brings us to an interesting situation: any provably safe and effective alternative medicine is not really an alternative medicine at all, but rather it becomes a conventional medicine.” 17

I couldn’t agree more and I think that’s exactly what we see in the case of acupuncture. Both the NHS in the UK and the NIH in the US consider acupuncture to be a recommended treatment for a growing number of conditions. Acupuncture is offered in an increasing number of hospitals in the US, due specifically to growing patient demand and clinical efficacy. The U.S. Military uses it to reduce pain medication and an increasing number of insurance providers cover it.

Acupuncture has pretty much gone mainstream in the West and the cool kids don’t really pick on it any more. But I guess, in spite of demonstrated biological mechanisms that are measurably distinct from placebo, its exemplary safety profile, and its vast and growing scientific evidence base, some haters always gonna hate. That’s ok, we’ll let them.

Notes:
1. Linde, K., Allais, G., Brinkhaus, B., Manheimer, E., Vickers, A., & White, A. R. (2009). Acupuncture for migraine prophylaxis (Review). Cochrane Database of Systematic Reviews, (1).
2. Tfelt-Hansen, P. (2006). A review of evidence-based medicine and meta-analytic reviews in migraine. Cephalalgia : an International Journal of Headache, 26(11), 1265–1274. doi:10.1111/j.1468-2982.2006.01194.x
3. Singh, D. S., & Ernst, P. E. (2009). Trick or Treatment? Random House.
4. Enck, P., Klosterhalfen, S., & Zipfel, S. (2010). Autonomic Neuroscience: Basic and Clinical. Autonomic Neuroscience: Basic and Clinical, 157(1-2), 68–73. doi:10.1016/j.autneu.2010.03.005
5. Paul A Offit, M. D. (2013). Do You Believe in Magic? Harper.
6. James, J. T. (2013). A new, evidence-based estimate of patient harms associated with hospital care. Journal of Patient Safety, 9(3), 122–128. doi:10.1097/PTS.0b013e3182948a69
7. FASTSTATS – Leading Causes of Death. (n.d.). FASTSTATS – Leading Causes of Death. Cdc.Gov. Retrieved July 2, 2014, from http://www.cdc.gov/nchs/fastats/leading-causes-of-death.htm
8. Hammerschlag, H. M. R., & Hammerschlag, R. (2012). Acupuncture and the Emerging Evidence Base: Contrived Controversy and Rational Debate. Journal of Acupuncture and Meridian Studies, 5(4), 141–147. doi:10.1016/j.jams.2012.05.001
9. Ernst, E., Lee, M. S., & Choi, T.-Y. (2011). Acupuncture: Does it alleviate pain and are there serious risks? A review of reviews. Pain, 152(4), 755–764. doi:10.1016/j.pain.2010.11.004
10. Ioannidis, J. P. A. (2005). Why Most Published Research Findings Are False. PLoS Medicine, 2(8), e124. doi:10.1371/journal.pmed.0020124
11. Sismondo, S. (2008). How pharmaceutical industry funding affects trial outcomes: Causal structures and responses. Social Science & Medicine, 66(9), 1909–1914. doi:10.1016/j.socscimed.2008.01.010
12. Lexchin, J. R. (2004).Implications of Pharmaceutical Industry Funding on Clinical Research. Annals of Pharmacotherapy, 39(1), 194–197. doi:10.1345/aph.1E224
13. Dorsey, E. R. (2010). Funding of US Biomedical Research, 2003-2008. Jama, 303(2), 137. doi:10.1001/jama.2009.1987.
14. Singh, D. S., & Ernst, P. E. (2009). Trick or Treatment? Random House.
15. McDonald, J. L., Cripps, A. W., Smith, P. K., Smith, C. A., Xue, C. C., & Golianu, B. (2013). The Anti-Inflammatory Effects of Acupuncture and Their Relevance to Allergic Rhinitis: A Narrative Review and Proposed Model. Evidence-Based Complementary and Alternative Medicine, 2013(4), 1–12. doi:10.1007/s00424-005-1457-8
16. Cho, Z. H., Hwang, S. C., Wong, E. K., Son, Y. D., Kang, C. K., Park, T. S., et al. (2006). Neural substrates, experimental evidences and functional hypothesis of acupuncture mechanisms. Acta Neurologica Scandinavica, 113(6), 370–377. doi:10.1111/j.1600-0404.2006.00600.x
17. Singh, D. S., & Ernst, P. E. (2009). Trick or Treatment? Random House.