Does Acupuncture Work for Pain?

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.”

Even proponents of acupuncture have prominently, publicly admitted that it doesn’t work. The best example of this is the infamous case of the 2010 New England Journal of Medicine paper, in which the pro-acupuncture authors clearly admit that “sham acupuncture was as effective as real acupuncture” (and yet they endorsed it anyway, because they are pro-acupunture).2

Nor is acupuncture even entirely 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.3 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.”4

This is in stark contrast to what most people believe about acupuncture.

Acupuncture for pain enjoys a strong reputation

Acupuncture is 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.5

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. 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.

As research methods improved, however, the evidence weakened.

Why hasn’t acupuncture cured everyone?

Strangely, even as acupuncture’s popularity has soared, all kinds of chronic pain problems continued to plague North Americans — possibly in record numbers.6 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.7

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”8 better than 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 really have surgery without anaesthetic?

Making sense of the “anaesthetic” effect of acupuncture

Yes, James Reston undoubtedly did get his appendix out without a chemical anaesthetic. There’s no particular reason to doubt his account, and there were witnesses. As I understand it, it’s actually a fairly common procedure in China. But there are some important considerations:

Acupuncture treatments, as sold in most places, are used to try to treat specific health conditions and chronic pain. An anaesthetic effect is simply a totally different animal. It’s like comparing apples and orange cars.

It’s actually not all that unusual for human beings to endure awful things without anaesthetic. My father, a Vietnam veteran who has both witnessed and experienced extreme traumas, demonstrates this himself 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) more than you might expect.

So, while it might seem spooky that Reston (and many others) have had acupuncture as an “anaesthetic,” the truth is that it’s actually just not nearly as interesting a phenomenon as it might seem to be at first. It was made special only by the sensationalism with which it got reported and repeated.

It’s actually not that unusual for human beings to endure awful things without anaesthetic.

And, in any case, dramatic anaesthetic-like effects are not even discounted by these researchers. In fact, Madsen et al acknowledge that significant variation in the responses to acupuncture (and sham acupuncture) “remains unexplained and calls for further studies.” In other words, people can have a powerful anaesthetic-like experience with acupuncture. But they are also definitely interpreting it as a dramatic example of a placebo effect, and they definitely found no evidence that such effects can be reliably reproduced as a therapy for many types of chronic pain. Probably because such a strong placebo effect depends strongly on a perfect storm of factors that just don’t exist down at Acupuncture Mart.9

There is a world of difference — a “culture” of difference, I should say — between what James Reston experienced, and going to down the acupuncturist at the mini-mall for your low back pain. Mr. Reston’s appendix was in the process of exploding far from home. He was swept up in an emotionally intense and alien experience of consciously undergoing surgery in a hospital in China: the fear and wonder of it all undoubtedly added up to a situation that is extremely different than anything you can possibly experience going to an acupuncturist here in North America.

I was in an acupuncturist office this morning, by chance — no drama there! Just the usual cheesy alternative medicine decor,10 and a shy young woman who couldn’t make eye contact, doubtless anxious to sell her services in a tanking economy. Nope, no chance of me getting swept up in a powerful placebo effect there …

This is why Madsen et al wrote, “to regard placebo acupuncture as a universally effective ‘super placebo’ would be inappropriate.” To get a ‘super placebo’ from acupuncture, you’re probably going to need rather a lot of emotional drama surrounding the treatment.

Acupuncture’s glory days are over

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 reviews11 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 are 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.

No, it isn’t “the last word” — there’s always more to study, more to learn — but it 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.12

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.

Practically everything I once optimistically believed about acupuncture has been crumbling for years. Science blogger Orac explains a similar evolution in his thinking. He’s written it so clearly that I might as well just give him the last word:

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.

Further Reading

• “Science-Based Medicine Acupuncture Resource Page,” a collection of resources at ScienceBasedMedicine.org. SBM’s excellent resource pages examine a topic in detail from the perspective of science-based medicine, as opposed to evidence-based medicine. (See Why “Science”-Based Instead of “Evidence”-Based?)
• SY Tantalizing Research About Acupuncture For Low Back Pain — Compelling new acupuncture evidence … with a twist ending
• SY Alternative to What? — “Alternative” health care professionals need to decide what they are really the alternative to
• SY Acupuncture for Neck Pain — Even the most trusted sources of medical information must be questioned
• SY Choose the Therapist, Not the Therapy — When you’re in pain, you want to know “what works,” but what you should look for is an honest therapist of any kind
• SY Does “Lose the Back Pain” Actually Help Low Back Pain? — A review of the popular low back pain treatment system

And of course …

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Notes

1. Madsen et al. “Acupuncture treatment for pain: systematic review of randomised clinical trials with acupuncture, placebo acupuncture, and no acupuncture groups.” British Medical Journal. 2009. Full Abstract:
   

   OBJECTIVES: 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.

   Return to text.
2. Berman et al. New England Journal of Medicine. 2010. 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!
   
   The best criticisms of the NEJM’s editorial choices here can both be found on Science-Based Medicine, by Drs. Crislip and Novella. Dr. Crislip’s post is quite funny. Return to text.
3. Woo et al. British Medical Journal. 2010. 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.”
   
   A common objection to Woo’s article has been that it is “mongers fear” and that he cites old evidence, from the 1970s and 1980s, before sterized needles were widely used. But critics conveniently overlook that Woo also cite modern evidence of infection — about as blatant a case of biased interpretation as you could ask for. And is Woo a fear mongerer? He does not claim that the risk is great: he just reports what is known and titles his piece neutrally. It is always worthwhile to examine treatment risks, and especially when treatment benefits are also hotly disputed. It hardly constitutes “fear-mongering” to report risk data in a medical journal! If not there, then where? Return to text.
4. Working as a Registered Massage Therapist, I routinely saw placebo backfire in this way. Pain patients in general, and low back pain patients in particular, are already strongly predisposed to anxious assumptions that their problem is “really bad.” When the placebo effect of acupuncture wears off, as it must, this anxiety is reinforced and the pain is elevated to the status of a fiercer enemy. A nice trap. I describe this in a little more detail in Save Yourself from Low Back Pain! Return to text.
5. Skeptics would often acknowledge (somewhat reluctantly) that traditional Chinese medicine is so different from Western medicine, in so many ways, that there was probably something of medical interest going on, somewhere, somehow, in the world of acupuncture. It’s easy to state the case so broadly that it’s nearly impossible to disagree with: yes, there’s probably “something” of medical interest, “somewhere” in traditional Chinese medicine! Return to text.
6. Although unsubstantiated and extremely difficult to prove, there seems to be evidence that several kinds of chronic pain, especially low back pain, have become much more common than they used to be. See Save Yourself from Low Back Pain! for some more information about that. Return to text.
7. Sure, yes, I understand and appreciate that “cured” patients would probably not have come to see me later on for the same problem. However, I’m really plugged into the lives of a lot of pain patients, and there is simply no theme of acupuncture-cure stories. No one comes in for wrist pain and comments that “I used to have neck pain, too, but it was cured by an acupuncturist.” The stories just aren’t there, in my experience. The stories that are there are the failure stories. Seemingly every other patient who’s been through the “therapy grinder” (tried everything) has received acupuncture that did little or nothing to help them. Return to text.
8. Madsen et al’s analysis shows that real acupuncture works slightly better than placebo — but by so little that it’s not even remotely exciting. The difference could easily just be due to the fact that real acupuncture is slightly more convincing, on average, than sham acupuncture — and thus there’s a better placebo effect! Return to text.
9. The wishful thinker will be inclined to say, “But maybe there is an effect and it’s just erratic, hard for science to pin down!” Perhaps. But any effect that is so hard for science to pin-down that we can’t even prove it exists is also next to useless in practice. If a standardized treatment protocol can’t deliver the goods in a somewhat reliably fashion, it’s not really medicine — or at least it’s not medicine I want to spend my money on until it’s “erratic” nature is better understood. Return to text.
10. Obligatory fountain, obligatory Chinese characters, obligatory business card with DaVinci anatomy, obligatory lame diploma … you get the picture. Return to text.
11. Cochrane reviews are generally considered to be the most authoritative summaries of the science on a topic so far. Return to text.
12. Paula Kamen writes brilliantly and hilariously about the inadequacy of “subtle” treatments in All In My Head: An epic quest to cure an unrelenting, totally unreasonable, and only slightly enlightening headache. Return to text.