SaveYourself.ca • Sensible advice for aches, pains & injuries
published 2/02/09, updated 12/16/11
No better than fake acupuncture, research shows. Again. And again. And again.
In early 2009, the British Medical Journal published a new analysis of acupuncture for pain … with discouraging results.1 Again! Not the first time. Not the last.
More recently and dramatically, the journal Pain did it again — one of the top ten journals for pain and injury science. In early 2011, Pain published a thorough and rather harsh scientific smack down of acupuncture, concluding that there is “little truly convincing evidence that acupuncture is effective in reducing pain.”2
Even proponents of acupuncture have admitted that it doesn’t work.3 The best example of this is the infamous case of the 2010 New England Journal of Medicine paper in which pro-acupuncture authors clearly acknowledged that “sham acupuncture was as effective as real acupuncture” … and yet they endorsed it anyway.4 Similarly, the taxpayer boondoggle NCCAM, a huge organiztion funded by American taxpayers to research alternative medicine, continues to research acupuncture “even though many of its studies have found that acupuncture … work no better than a sham treatment at easing symptoms like pain and fatigue.”5 If NCCAM won’t say that acupuncture works, who can?
All of this is in stark contrast to what most people believe about acupuncture. People actually think science supports acupuncture. That simply isn’t the case.
Somehow, acupuncture has managed to become the poster child of alternative medicine. Almost everyone seems to believe that there “must be something to it.” Until the last few years, even many hardened skeptics and critics gave it a bit of a pass.6 But beliefs about acupuncture are much more specific than that: health care consumers and professionals particularly tend to believe that acupuncture is “good for pain.”
When North Americans think of using acupuncture for pain relief, they often visualize an almost magical anaesthetic effect. This mental image comes to us direct from the year 1972, when journalist James Reston wrote about his appendectomy during American President Nixon’s trip to China — he was apparently “anaesthetized” with acupuncture needles. Now that’s a dramatic effect!
Consequently, most Westerners believe that acupuncture is good for pain, if not downright amazing for pain. And, throughout the 1970s and 80s, scientific research — of questionable quality — seemed to back that up. For a while.
As research methods improved, however, the evidence weakened.
And scholarship about acupuncture has produced constant parade of smart debunkery and facts embarrassing to acupuncture, showing that it has all the characteristics of modern faddism, not ancient Chinese wisdom. Acupuncture’s “meridians” corresponded mainly with the big, obvious blood vessels and were basically all about bloodletting.Indeed, even in China, acupuncture’s key concepts have a dubious history and provenance. For instance, Ben Kavoussi, a doctor and acupuncturist himself by training (and therefore an unusually credible critic) has explained how the supposedly “ancient” and mystical meridians of acupuncture are actually based on quite modern and arbitrary interpretations78 — not so ancient after all, and not consistent, either. Prior to their modern incarnations, the meridians corresponded mainly with the big, obvious blood vessels and were basically all about bloodletting — exactly like the prescientific medieval European practice, and not related to any proposed magic forces.
Then there’s the myth of acupuncture’s popularity. Even its alleged popularity and widespread use in China is quite trumped up — it is, for instance, not really used for anaesthesia. The anaesthia and popularity myths will be described more below.
Such historical perspectives are extremely useful in understanding how naively over-rated acupuncture has become in the world today.
“I put the needles in me instead of in you.”
“I put the needles in me instead of in you.”
Probably not the way acupuncturists want us to think it is. Brennen McKenzie for ScienceBasedMedicine.org:9
I don’t believe the quality of the data generally allow very confident statements about the popularity of acupuncture. However, proponents of acupuncture often make such statements, trying to convey the impression that their approaches are growing rapidly in popularity and only perverse, closed-minded curmudgeons still resist them. The little evidence we have certainly does not support such claims.
There’s no question that acupuncture is somewhat popular. It’s certainly on the public’s radar as an option, something that might be “worth a shot.” However, it is still an option that mostly only desperate pain patients try, and no way is it even nipping at the heels of mainstream medicine in terms of market share; it remains a trivial, marginalized player in health care. It is not even remotely winning over every patient. Only quite rarely do I hear from a reader or a patient who “swears by” acupuncture, and of course the most emphatic testimonials invariably suffer from obvious flaws, such as recovery that could well have been powered by placebo, a concurrent treatment, or coincidence with natural healing.
Far more commonly, the reports are tepid and uncertain — “I think it might have made a difference” — or frankly negative — “Didn’t do a thing. Waste of money.” Hardly the stuff of serious popularity there.
Strangely, even as acupuncture has become popular for an alternative therapy, all kinds of chronic pain problems continued to plague North Americans — quite possibly in record numbers.10 After working for more than decade with chronic pain patients of all kinds, I have yet to see anyone “cured” by acupuncture, even though large numbers of them have certainly tried.11
Modern scientific studies of acupuncture (from the last 10–20 years) effectively compare real acupuncture to fake or sham acupuncture. Fake acupuncture involves the insertion of needles into non-acupuncture points, or the use of non-penetrating needles (kind of like a stage dagger, where the blade collapses into the handle). It may be difficult or impossible for the patient to tell whether or not they are receiving “real” acupuncture.
“For example,” Madsen et al write, “when patients are asked whether they feel Qi, a high proportion of patients will say yes, even when they have been treated with a non-penetrating placebo acupuncture needle.”
What all the newest research shows, time and again, is that both real acupuncture and fake acupuncture perform equally well. That is, they both “work”12 as well as a placebo, neither of them routinely work any miracles, and they have the same effect regardless of whether or not the needles are being used according to the principles of traditional Chinese medicine.
So … what happened to James Reston? Did he actually have surgery without anaesthetic?
He did not! Telling his story in the introduction was a kind of setup.
By his own account, Reston had a regional anaesthetic. In an extremely thorough and articulate series for ScienceBasedMedicine.org,13 Dr. Kimball Atwood presents a strong case that the “acupuncture anesthesia” promoted from about 1958 through the mid-1970s by the People’s Republic of China — and becoming a powerful myth in North America and Europe — was actually faked. Like Reston, most patients who underwent acupuncture for surgery were given also sedatives, narcotics, and local anesthetics. Statistics about the use and effectiveness of “acupuncture anesthesia” were grossly exaggerated. During the Cultural Revolution, patients were under extreme pressure to please their physicians and other authority figures, which meant they were unlikely to complain. In the late 1970s, when criticism became safe, knowledgeable doctors began speaking out publicly about the fakery, and use of and respect for Traditional Chinese Medicine has been declining in China since that time. There is no longer any acupuncture anesthesia or analgesia — at least not to an extent that is either humane or clinically useful for surgery.
Although it's true that people can withstand painful procedures without anesthesia to a greater extent than is generally acknowledged in this era of safe anesthesia, the history of acupuncture "anesthesia" in the Peoples' Republic of China is mainly one of state-sponsored torture.
— Dr. Kimball Atwood
Acupuncture treatments, as sold in most places, are used to try to treat specific health conditions and chronic pain. Even if that worked, a true I-can’t-feel-anything anaesthetic effect would be a totally different animal (and a much bigger one). Using acupuncture for anaesthesia actually is almost as impossible and absurd as it sounds. You don’t want to try it, any more than you want to try getting a tooth pulled after a good belt of whisky. Using acupuncture for anaesthesia actually is almost as impossible and absurd as it sounds. You don’t want to try it, any more than you want to try getting a tooth pulled after a good belt of whisky.
It’s actually not all that unusual for human beings to endure awful things without any kind of anaesthetic. My father, a Vietnam veteran who has both witnessed and experienced extreme traumas, demonstrates this himself occasionally by submitting to dental drilling without freezing — “I hate the freezing so much, I’d rather just deal with the pain and get it over with.” There are numerous social and personal factors that can lead to high pain tolerance … and it can be completely situational. Ask any nurse or doctor: people are full of surprises, and often hurt much less (or much more) than you might expect.
So, while it might seem spooky that anyone has used acupuncture as an “anaesthetic,” it’s actually just not nearly as interesting a phenomenon as it might seem to be at first. Madsen et al interpret this kind of pseudo-anaesthesia effects as a dramatic example of a placebo effect and they definitely found no evidence that such effects can be reliably reproduced. “To regard placebo acupuncture as a universally effective ‘super placebo’ would be inappropriate.” To get a ‘super placebo’ from acupuncture, you need rather a lot of emotional drama surrounding the treatment — which probably depends strongly on a perfect storm of psychological factors that just do not and cannot exist at a low-rent acupuncture office in a mini mall.14
There is a world of psychological difference between experiencing acupuncture in its native cultural context, and experiencing it as a commercialized fad in North America. I was in an acupuncturist’s office this morning, by chance. It had the usual cheesy alternative medicine decor — obligatory fountain, Chinese characters, Vitruvian Man on the business card, cheap diploma — and the acupuncturist was a shy young woman who couldn’t make eye contact, doubtless anxious to sell her services in a struggling economy. It was pretty uninspiring, honestly. In that bland environment, there was no chance of me getting swept up in a powerful placebo effect there … even if I wasn’t a skeptic.
It’s all but over for acupuncture as a pain treatment. I’m not reporting on science news that casts doubt on acupuncture — I’m reporting on science news that puts another nail in the coffin, a nail that probably wasn’t even necessary. Madsen et al write:
“Our finding of limited, at best, analgesic effects of acupuncture corresponds with the seven Cochrane reviews15 on acupuncture for various types of pain, which all concluded that no clear evidence existed of an analgesic effect of acupuncture.”
In other words, this isn’t really news. They were just confirming what was already painfully clear: the evidence was already overwhelming that there is simply nothing of great interest going on in acupuncture except some interesting placebo.
There’s always more to study, more to learn — but all of this evidence is certainly the death of any realistic hope that acupuncture is anything more than an ancient Chinese superstition. Even the most optimistic assessment of the existing scientific research can grant acupuncture no more than the slight possibility of subtle efficacy.
Whoopty-do. Who wants “subtle” when you’re in agony? Treating serious pain is serious business. There’s not much room for “subtle” benefits when you’re trying to help people who are in agony.16
So it’s time to move on. Dr. Harriet Hall:
More studies are not the answer. No matter how many studies showed negative results, they would not persuade true believers to give up their beliefs. There will always be “one more study” to try, but there should be a common-sense point at which researchers can agree to stop and divert research time and funds to areas more likely to produce useful results.
Acupuncture wouldn’t bother me so much if there were nothing better to think about, no better research to be discussing. But people are suffering from real, horrible chronic pain — they write to me every day, and statistics about chronic pain are thoroughly alarming — and there is urgent work to be done finding solutions for them, and educating both patients and professionals about realistic, rational options.
At best, acupuncture is a waste of valuable time — and now so is the debate about it. I haven’t heard an original or valid argument in defense of acupuncture in years,17 and I haven’t seen any compelling evidence ever I haven’t heard an original or valid argument in defense of acupuncture in years, and I haven’t seen any compelling evidence ever., because it doesn’t exist. As every critic of acupuncture has explained ad infinitum, the most favourable evidence available is also the oldest, weakest and the most biased, and even that evidence is underwhelming, benefits that barely register as clinically significant — much ado about not much, even if it’s actually real, which no better study has ever confirmed.
Carl Sagan was famously asked the Dalai Lama what would happen to Tibetan Buddhism if proof that there is no reincarnation could be found. The Dalai Lama replied:
Then Tibetan Buddhism would have to change.
And it should be no different for acupuncture. If new evidence emerges that shows that it isn’t what we all hoped it would be, then it must change. That evidence has emerged. Practically everything I once optimistically believed/hoped about acupuncture has been crumbling for years. Science blogger Orac explains a similar evolution in his thinking.
Believe it or not, there was one area of so-called “alternative” medicine that I used to be a lot less skeptical about than I am now. Homeopathy, I always realized to be a load of pseudoscientific magical thinking. Ditto reiki, therapeutic touch, and other forms of “energy healing.” It didn’t take an extensive review of the literature to figure that out, although I did ultimately end up doing fairly extensive literature reviews anyway. Then, the more I looked into the hodgepodge of “healing” modalities whose basis is not science but rather prescientific and often mystical thought, the less impressed I was.
Even so, there was always one modality that I gave a bit of a pass to. There was one modality that, or so I thought, might actually have something to it. There was one modality that seemed to have a bit of suggestive evidence that it might do something more than a placebo. I’m referring to acupuncture. No, I never bought all the mystical mumbo-jumbo about how sticking needles into “meridians” somehow alters or “unblocks” the flow of a mysterious “life force” known as qi that is undetectable by science. I did wonder if perhaps it worked as a counterirritant or by releasing endorphins.
Then I actually started paying attention to the scientific literature regarding acupuncture, including literature like this and this. The more I read, the more I realized something. I realized that there was far less to acupuncture than I had previously thought, and, even with my previous openness to it, I hadn’t thought all that much about it anyway. What I had thought about it was that it might have a very mild beneficial effect. What I know now is that acupuncture is almost certainly no more than an elaborate placebo. What I know now is that virtually every study of acupuncture claiming to show a positive effect has serious methodological flaws and that the better-designed the study the less likely there is to be an effect.
To conclude, I want to emphasize that acupuncture is not actually even safe.
As with any treatment that breaks the skin, disastrous infection is possible, and outbreaks of mycobacteria infection caused by acupunture have been reported in the last decade.18 Furthermore, placebo effects tend to backfire: the patient is betrayed in the end, and the failure to achieve a lasting cure paradoxially cements the patient’s idea their pain is untreatable, “even by acupuncture.”19
Ernst et al did a good job of backing this up, and explained that “serious adverse effects continue to be reported,” such as infections and collapsed lungs. Nothing like a little sepsis and collapsed lung to add to the fun of chronic pain!
Of course these risks are not common complications. And when medicine works, costs and risks are acceptable, even a “no brainer.” But if there are no clear, consistent, measurable benefits to a treatment?
Then there is no justification for any risk.
I used to “believe” in acupuncture. I think almost everyone did. Probably not this guy. And probably not this one either. But just about everyone else, even skeptics, cut acupuncture some slack.
Over the years, I have been persuaded by more and more good quality evidence — and the steady stream of patients with nothing better to say about it than “maybe it helped for a while” — that there is really nothing at all to acupuncture. It’s just another folk medicine tradition, about as therapeutically meaningful as a manicure.
So how did it feel to change my mind? Oh, a little awkward. It was like diving into water you just know is cold enough to make you gasp. I felt some emotional resistance to the evidence. I also remember feeling comforted whenever I read anything that seemed to bolster my besieged beliefs I felt some emotional resistance to the evidence. I also remember feeling comforted whenever I read anything that seemed to bolster my besieged beliefs., and there was plenty of that. It took me quite a while to notice the disturbing pattern that the evidence supporting acupuncture was of consistently lower quality, while the evidence undermining it was of consistently higher quality.
Things started to get more comfortable when I noticed that I rather liked the doctors, scientists and skeptics who were challenging acupuncture. They seemed ridiculously bright — and I like bright people. I actively seek out people who are smarter than I am, because I figure it’s the most obvious way to get smarter: you are who you hang out with. I certainly didn’t like them because they agreed with me on much of anything, because we didn’t agree at that time. But they won me over.
Having my beliefs challenged by such intelligent people was uncomfortable at first, but it was overshadowed by the desire to understand. Despite my initial reluctance, in the end I’m proud to say that I was much more interested in just knowing how the world works than anything else.
BACK TO TEXTOBJECTIVES: To study the analgesic effect of acupuncture and placebo acupuncture and to explore whether the type of the placebo acupuncture is associated with the estimated effect of acupuncture.DESIGN: Systematic review and meta-analysis of three armed randomised clinical trials.DATA SOURCES: Cochrane Library, Medline, Embase, Biological Abstracts, and PsycLIT. Data extraction and analysis Standardised mean differences from each trial were used to estimate the effect of acupuncture and placebo acupuncture. The different types of placebo acupuncture were ranked from 1 to 5 according to assessment of the possibility of a physiological effect, and this ranking was meta-regressed with the effect of acupuncture.DATA SYNTHESIS: Thirteen trials (3025 patients) involving a variety of pain conditions were eligible. The allocation of patients was adequately concealed in eight trials. The clinicians managing the acupuncture and placebo acupuncture treatments were not blinded in any of the trials. One clearly outlying trial (70 patients) was excluded. A small difference was found between acupuncture and placebo acupuncture: standardised mean difference -0.17 (95% confidence interval -0.26 to -0.08), corresponding to 4 mm (2 mm to 6 mm) on a 100 mm visual analogue scale. No statistically significant heterogeneity was present (P=0.10, I(2)=36%). A moderate difference was found between placebo acupuncture and no acupuncture: standardised mean difference -0.42 (-0.60 to -0.23). However, considerable heterogeneity (P<0.001, I(2)=66%) was also found, as large trials reported both small and large effects of placebo. No association was detected between the type of placebo acupuncture and the effect of acupuncture (P=0.60).CONCLUSIONS: A small analgesic effect of acupuncture was found, which seems to lack clinical relevance and cannot be clearly distinguished from bias. Whether needling at acupuncture points, or at any site, reduces pain independently of the psychological impact of the treatment ritual is unclear.
Comments: A dozen of the best scientific studies of acupuncture treatments for pain were carefully analyzed. The acupuncture treatments were for conditions like osteoarthritis, headache and migraine, low back pain, fibromyalgia, and more. The authors of the paper found a statistically significant but “small difference between acupuncture and placebo acupuncture.” They concluded that “the apparent analgesic effect of acupuncture seems to be below a clinically relevant pain improvement.”
Comments: A bizarre and already infamous paper: bizarre because the authors clearly acknowledge that acupuncture is no better than a placebo, and bizarre because they conclude that it should be recommended, and most bizarre of all because it is published in The New England Journal of Medicine. Truly, one of the lowest moments in the history of that famous journal!
CAM: Taxpayer money spent on studies with questionable scientific value. Tsouderos. 2011.
NCCAM has also gotten around no-better-than-placebo findings essentially by fluffing up the importance of the placebo effect and claiming that it is inherently interesting. Tsouderos explains: “To most scientists, that would mean the treatments are failures — drug companies cannot sell medicines that work no better than salt water or a sugar pill. But in the case of acupuncture and other mind and body medicine, the center and its supporters say it's unclear whether the benefits represent a placebo response or something more complicated” — something more complicated meaning, basically, a really good placebo effect.
Officially, and with regards to other kinds of treatments like saw palmetto, “NCCAM considers studies finding that a supplement does no better than a placebo to be evidence that it does not work.” But NCCAM has failed to apply the same standard to acupuncture, and continues to spend vast sums of money to prove over and over again that acupuncture cannot do better than placebos.
“And yet, instead of declaring these studies convincingly negative, NCCAM is pouring more research money into acupuncture. ‘The intellectual dishonesty is just astounding,’ said Dr. Steven Novella, a neurologist at Yale School of Medicine and a critic of NCCAM. ‘They are just quietly changing the question and the rules.’
BACK TO TEXT Comments: What’s the harm in acupunture? A small but real risk of infection — as with anything that breaks the skin. Acupuncture has not only failed to prove that it works, but this British Medical Journal editorial presents new evidence that it also involves a risk of mycobacteria infection, and even that “… outbreaks of acupuncture transmitted infections may be the tip of the iceberg. The first reports of meticillin resistant S aureus (MRSA) transmitted by acupuncture appeared in 2009. The emergence of community associated MRSA infections may aggravate the problem.”