Let’s conduct a hypothetical clinical trial of a new drug that may reduce pain. We’ll take 3000 patients and assign them to three groups randomly. We’ll give group 1 no treatment. Group 2 will receive a sugar pill containing no active substances, and Group 3 will get our drug. We’ll track our patients for several months and measure objective responses. I’ve drawn a chart of change in reported pain status on a 1 to 100 scale at the time of follow-up. Notice that Group 1, our no-treatment, has essentially no change. Group 3 shows some improvement, however small, but Group 2 shows the greatest response. Remember that this is the group that got only sugar pill. What should we conclude about our drug? What could cause such a difference between no-treatment and a sugar pill? Is sugar an effective treatment for pain? Don’t forget this example, because we’ll be coming back to it.
Placebo describes our ability to respond to inactive substances or stimuli by way of suggestive guidance. A placebo sugar pill can be more effective at relieving pain than no sugar pill, even though the sugar is ineffective at biologically interfering with the pain response. The placebo response is measurable in subjective tests like the visual analog pain survey, but it’s also measurable in objective tests like blood pressure and pulse rate. It has a real biological effect, and we shouldn’t ignore it. This says a lot about our creative brain and the power it has over our biology. It takes an expectation and turns it into a reality. Many cultural traditions recognized this long before the advent of modern psychology, and healers have been using the placebo effect for non-life threatening conditions for millenia. There’s an interesting correlation between the nature of the placebo intervention and the degree of response. Medical research has established that placebo capsules are more effective than placebo in pill form.
Large capsules are more effective than small capsules. At the very top of effectiveness on the list are two placebo treatments, injection and acupuncture. It would seem the more intense the sensation of the placebo, the more confidence we gain from it, and the stronger the suggestion of efficacy. Sticking needles in our skin, we might subconciously reason, is bound to be effective, because it’s so extreme. I want to deal specifically with the idea of acupuncture in its modern form. This is the belief that a needle inserted in the skin by a skilled practicioner can activate qi, an invisible vitalist fluid that runs through the body to give function to the organs. Now I don’t have the time to go through the long and detailed history of acupuncture. Suffice it to say that the belief in qi and acupuncture is a largely supernatural belief akin to the belief in humors and blood-letting in Europe, and about as accurate.
There are many variations and types of acupuncture that correspond to different traditions. Some practicioners burn plant material on the needles, called moxibustion. Others use electrical stimulation through the needles, or a recent addition, cool lasers. What is most important for this discussion is that an acupuncture session involves sitting quietly while a trusted authority figure shoves needles into your skin. There’s a great deal of manual contact, as the practicioner inserts the needles and applies certain motions, and an sense of relaxation. This creates an atmosphere of high suggestibility, and frequent painful stimuli followed by release, something that can stimulate the release of endorphins. We could also include acupressure here, which doesn’t penetrate the skin, but simply puts pressure on specific chi points. So, does it work? The short answer is yes. In the short term, say less than 2 days, you will feel some relief from certain kinds of pain. The magnitude is very small in the clinical trials that have been run, say 2 to 6 points out of a 100 improvement over no therapy for a variety of painful conditions from arthritis to tooth pain. We could certainly walk away at this point and conclude that acupuncture is very slightly effective on the evidence.
Many of the studies conducted by professional acupuncturists do. But the comparison doesn’t have to just be between no treatment and acupuncture. We can also include a sham treatment, a placebo of acupuncture, if you will, just like we would for a drug trial. We have some options here. Some have used regular acupuncture needles, but not placed them in qi points. Some use the needles in the right places, but don’t adjust them correctly, or insert them deeply enough. My favorite, though, and the study I want to discuss, used… wait for it… toothpicks in place of acupuncture needles as a sham treatment. Can we agree in advance that if sham acupuncture with toothpicks works as well as regular acupuncture, that’s a clear placebo response? Because that’s not what they found.
No, they found that toothpick acupuncture works better than the real thing. And not just a little, but a lot. Both of them beat the no-treatment group, but the toothpick group was the clear winner. In fact, the example I gave at the beginning are the numbers from this study, conducted by the NIH office of Complementary and Alternative Medicine. The other placebo group often examined, the placement of needles not in qi meridians, but rather randomly, or improperly placed, or placed too shallow, often outcompete the conventional acupuncture in these type of randomized patient-blinded trials. If a drug company came up with these kinds of results, they would quietly slink away.
Not the acupuncturists, though. They’re quite happy with the finding, suggesting that acupuncture works so well, it doesn’t even matter if needles are inserted or not… Clearly, they all missed the day in acupuncture class when evidence based medicine was taught. For me, this is the end of any discussion about acupuncture. But if anyone out there still has doubts, even after the systematic reviews by the Cochrane Institute and others dismiss any effectiveness versus placebo, I would ask you to consider the very real risks.
That’s right, sticking needles in your body has some associated risk. I know you’re all shocked. If those needles are improperly sterilized or handled, they can introduce bacteria deep into tissue. If they’re inserted too deeply, they can puncture membranes like the lungs, the spine, and the heart. If they break off inside your tissue, removal may require surgery. So the possible side effects of acupuncture are infection, tissue and nerve damage, major surgery and death. Is that worth a 2% reduction in pain? I don’t think so. How likely are these adverse outcomes? In a survey of adverse events of acupuncture given to about 1000 doctors and 200 acupuncturists in Finland in 1995 (Norheim and Fonnebo, 1995), there were 25 cases of pneumothorax, or punctured lung, reported by doctors.
This gives a prevalence in Finland of about 250 cases in about 5 million people, or 5 per 100,000 people. But the number of licensed acupuncturists in Finland is only about 500, and presumably they only treat a few thousand people, elevating the risk substantially for those who use the services. Now, not all pneumothorax are fatal, many spontaneously heal, but there is a risk of lung collapse and very rapid death. There are numerous case reports too horrifying to list here. X-rays revealing broken needle points in the pericardium, post-mortem exams of spinal lining punctures, and even a few outbreaks of infection from needles called acupuncture mycobacteriosis that infected dozens of people. If you do go to get needles inserted, make sure the practicioner is at least licensed, uses disposable needles, and that they carefully sanitize both their hands and your skin. I’m not a fan of scare tactics. But I think a thoughtful examination of the risks and benefit do not support the use of acupuncture for pain management or any other condition.
Placebo effect is a useful tool to be sure, but the next time you’re tempted to visit an acupuncturist, perhaps you might pursue the more effective, less expensive and probably safer alternative therapy. It’s all natural, composed entirely of wood, and also good for holding olives in a martini. Thanks for watching..