The Paradox of Acupuncture: The More Evidence-Based Popularity, The Stronger The Ensuing Skepticism

As an open-minded person and at the same time an acupuncturist, I am always more interested in learning the critical and skeptical opinions about acupuncture than listening to commendatory or advocating comments.

A Healing Art Struggling Its Way into Modern Medicine

With half century's struggling its way through strict scrutiny and critiques from rationalist skeptics, acupuncture continues to advance into mainstream American healthcare and into healthcare systems worldwide (David W. Miller, et al, 2021).

By now, few (including some skeptics) deny acupuncture is an evidence-based practice (EBP) that has been rigorously tested and regarded as both clinically effective and cost-effective for multiple conditions. However, this healing modality still remains the focus of persistent attacks by skeptics (Helen Langevin et al, 2018), and has not yet seen the intensity of incorporation into mainstream healthcare that it deserves on merit (David W. Miller, et al, 2021).

Despite the substantial body of basic science and clinical research in acupuncture, the practice of acupuncture continues to be steeped in a metaphorical language that is culturally foreign to the United States and to the biomedical paradigm.This leads to skepticism regarding the scientific basis of acupuncture and presents an essential challenge for integration into a conventional healthcare setting (Helen Langevin et al, 2018).

Evidence-Based Acupuncture in the United States

In 2021, Global Advances in Integrative Medicine and Health published an article authored by six American MDs, DCs and/or acupuncturist researchers which voiced for the enhancement of incorporating acupuncture Into American Healthcare. The article provided a big picture about how much acupuncture has already made inroads into mainstream medicine in the US as below:

• In recent years, acupuncture as practiced in the United States has emerged as an evidence-based therapy in a growing number of multidisciplinary guidelines, predominantly surrounding its use for pain. In 2015 the Joint Commission revised guidelines for the management of pain to include non-pharmacological strategies including acupuncture. In 2016, the American Society of Clinical Oncology included acupuncture for chronic pain management as part of their adult cancer survivor care recommendations. Acupuncture was noted to be effective for low-back pain by the Agency for Healthcare Research and Quality in 2016, which informed clinical practice guidelines by the 2017 American College of Physicians, which recommended acupuncture for acute and chronic low back pain. Similar recommendations for low back pain were adopted in the 2017 clinical practice guidelines of the Department of Veterans Affairs. Most recently, in January of 2020, the Centers for Medicare and Medicaid services approved the use of acupuncture for chronic low back pain.
• A recent article by Birch et al. surveyed trends in the inclusion of acupuncture into clinical practice guidelines and positive references to acupuncture between 1991 and 2017.The results included 2189 positive recommendations for acupuncture within 1311 publications, with an increasing frequency trend. Pain was the most common positive reference with 1486 references relating to 107 pain indications. There were 703 recommendations related to 97 non-pain conditions. The groups making these recommendations were noted to show significant diversity, coming from sources such as government health institutions, national guidelines, and medical specialty groups. The data came from around the world, but were especially abundant in Europe, North America, and Australasia.

Skepticism from Scientific Rationalists

As an open-minded person and acupuncturist, I am very familiar with quite a few big names of medical science skeptic rationalists, among whom there is medical doctor Harriet Hall, a retired Air Force physician and flight surgeon, who writes and educates about pseudoscientific and alternative medicine. She is a contributing editor and frequent contributor to the Skeptical Inquirer and contributes to the blog Science-Based Medicine.

Her persistent critiques of acupuncture always deepen my critical thinking in my writing of this Newsletter - The Truth of Acupuncture Science. One of her articles titled “Is Acupuncture Winning?” posted in 2019 in Skeptical Inquirer is particularly informative in that it demonstrated an interesting dilemma of acupuncture: its increasing popularity, albeit strongly evidence-based, only intensifies skeptics' belief that acupuncture is by all means a powerful theatrical placebo.

An Evidence-Based Theatrical Placebo

Dr Harriet Hall's article (2019) goes as below.

• Is Acupuncture Winning?
• When I first heard of acupuncture in medical school in the late 1960s, I became convinced that it worked. I read impressive media reports from China touting it for everything from pain relief to anesthesia for open heart surgery. Our Chief of Anesthesiology, Dr. John Bonica, was also convinced it worked and was studying it. As time passed, more and more studies were published, and Dr. Bonica eventually gave up on it. So did I.
• I monitored the evolving research with great interest. Originally acupuncture was claimed to work for a laundry list of things, but only two things passed the tests: pain and postoperative nausea and vomiting. Even for those, systematic reviews disagreed with each other, so in April 2011, Edzard Ernst et al. published a systematic review of systematic reviews of acupuncture for pain in the journal Pain.1 They found a mix of positive, negative, and inconclusive results. They found only four conditions for which more than one systematic review reached the same conclusion: three times they agreed that it didn’t work. The fourth time, they agreed that it did work—for pain in the neck. I was asked to write an accompanying opinion piece, which I titled “Acupuncture’s Claims Punctured: Not Effective for Pain, Not Harmless.”2 I wrote:
• … when a treatment is truly effective, studies tend to produce more convincing results as time passes and the weight of evidence accumulates. When a treatment is extensively studied for decades and the evidence continues to be inconsistent, it becomes more and more likely that the treatment is not truly effective. This appears to be the case for acupuncture. In fact, taken as a whole, the published (and scientifically rigorous) evidence leads to the conclusion that acupuncture is no more effective than placebo.
• I pointed out that it seemed very unlikely that a treatment for pain would only relieve pain in the neck but not elsewhere in the body. I pointed out the difficulty of doing good acupuncture research, since appropriate controls are hard to find, double blinding is next to impossible, and there are many kinds of “acupuncture”—including electroacupuncture, ear acupuncture, cupping, and many other variants. I pointed out that it doesn’t seem to matter where you put the needles or even if you use needles at all; one study found that touching the skin with toothpicks was equally effective! All that really seems to matter is if the patient believes in acupuncture and believes he got the real thing.
• My opinion was confirmed in 2013 when David Colquhoun and Steven Novella reviewed all the published evidence and published an article in the journal Anesthesia and Analgesia.3 They found that “the benefits of acupuncture are likely nonexistent, or at best are too small and too transient to be of any clinical significance,” and they concluded that acupuncture is a theatrical placebo.
• Other publications and organizations, including the Medical Letter, the Center for Inquiry, and Sciencebasedmedicine.org have all declared that acupuncture is ineffective except as a placebo.
• Should We Use Placebos?
• It is often argued that even if acupuncture is only a placebo, it does “please” many patients (after all, the word placebo is Latin for “I please”) so it is worthwhile using it. People say it does no harm, but Ernst et al. found ninety-five reports of serious harm to patients; some but not all of these could have been prevented by better sterile precautions and better education in anatomy. There are other harms, including the waste of time and money, and patients may be tempted to use acupuncture instead of treatments that are truly effective.
• And of course, we wouldn’t give patients a sugar pill placebo. Where do we draw the line? Medical ethicists universally condemn prescription of placebos because it constitutes lying to patients. Studies have been done where patients were aware that they were getting a placebo, but the researchers presented placebos in a way that led patients to believe placebos were effective. Just receiving a pill from a doctor is an indication to patients that it is supposed to work, creating the kind of suggestion that is likely to produce a placebo effect.
• The Missing Mechanism
• Acupuncture is “ancient wisdom” based on prescientific fumbling. The concepts of meridians and acupoints are mythical. They have never been detected by anatomists. The concept of a vital force, “human energy field,” qi, or chi is also mythical. Physicists have measured all kinds of energies down to the subatomic level but have never detected qi. Acupuncturists believe these myths and are so convinced that acupuncture works that they have tried to come up with a scientific rationale for how it might work.
• Remember Ray Hyman’s Categorical Imperative: “Do not try to explain something until you are sure there is something?to be explained.” Acupuncturists were sure acupuncture worked, so they proceeded to propose all kinds of hypothetical explanations of how it might work.
• It was shown to release natural pain-relieving endorphins in the brain, but so do placebos! Endorphins are released in the brains of animals when a stick is thrown for a dog or when a horse is trailered. The gate theory of pain offers a physiological explanation for the previously observed effect of psychology on pain perception. Was it just counter irritant effects, like hitting your thumb with a hammer to make you forget your headache? In a 2000 article in a Japanese journal, acupuncture, moxibustion, and a hemostat on the tail were compared as pain blocks in mice. The hemostat on the tail won! Researchers have looked at neurovascular bundles, trigger points, connective tissue fascial planes, areas of reduced electrical impedance, and enhanced migration of nuclear tracers. The studies are flawed and inconclusive, and they contradict each other. No consensus has been reached.
• We already have a perfectly good explanation of how acupuncture “works.” It is a theatrical placebo that is very good at eliciting placebo responses. Patients are impressed by the surrounding ritual and the “ancient wisdom” mumbo jumbo. They get personal attention from a charismatic provider. Appointments are long, and patients relax. They respond to TLC and hands-on treatment. Providers make strong suggestions that acupuncture will relieve symptoms, creating expectations in the patients. There are no specific effects, but there are many nonspecific effects of the provider/patient interaction. A famous study of asthma patients showed that patients subjectively felt better with an Albuterol inhaler, a placebo inhaler, or sham acupuncture but were only objectively better on lung function tests if they had used the Albuterol inhaler.
• Many People Believe
• So acupuncture doesn’t work except as a placebo, but it is widely perceived to work. By 2002, 8.2 million American adults had tried it. It has been infiltrating our hospitals and medical schools and even affecting our laws. As Jann Bellamy wrote on the Science-Based Medicine blog, “we are all too familiar with opinion and whim beating out science in legislation and regulations.” There are state laws promoting auricular acupuncture for substance abuse treatment. Medicaid has reimbursed doctors and hospitals for acupuncture treatment of drug addicts. Many medical insurance programs cover acupuncture. The World Health Organization (WHO) recognizes acupuncture as an effective form of treatment. The National Center for Complementary and Integrative Health (NCCIH) says it is effective for back pain and a few other conditions. The Mayo Clinic recommends it and says, “Increasingly, it is being used for overall wellness, including stress management.” The Harvard Health Blog says it’s worth a try for chronic pain. The Cleveland Clinic says it is effective for various conditions. The American Academy of Family Physicians (AAFP) recommends it as first-line noninvasive treatment for back pain and says electroacupuncture should be considered for patients with fibromyalgia. And many other professional organizations support using it.

Yes, There Is Evidence, But Wait, It Is Not Science-Based

Having realized acupuncture's pretty strong evidence base is not deniable, Dr Hall turned to take issue with acupuncture from the aspect of science. She continued to ague:

• What this boils down to is the difference between evidence-based medicine (EBM) as it is commonly practiced and science-based medicine (SBM) as it should be practiced. This was the reason we started the SBM blog, sciencebasedmedicine.org. For EBM, it is enough to have positive trials. They accept positive results of therapeutic trials based on fantasy, such as Reiki, homeopathy, and therapeutic touch. Trying to apply the tools of science to these therapeutic modalities based on fantasy just produces a lot of confusing noise. For SBM, we also look at other factors such as prior plausibility and compatibility with established science.
• There are many true believers in acupuncture. Personal experience is compelling. Patients who got better believe it works, but they may have succumbed to the post hoc ergo propter hoc fallacy (“after this, therefore because of this”). The rooster crowed, then the sun came up; therefore, the rooster made the sun come up. I got better after a treatment; therefore, the treatment made me better. That may be true, but sometimes it’s just as wrong as the rooster. The patient might have improved with no treatment, just from the natural course of the disease, or from some other factor that they don’t give credit to. Without a comparison control group, there’s no way to know.
• There Is Hope
• Acupuncture seems to be winning. Less-than-rigorous science is being accepted. Good evidence is being disregarded. A lot of patients and doctors are convinced it works.This has been called the Age of Endarkenment and the Post-Truth Era. But there is hope.
• Recently I gave a lecture at Ohlone College on “Evaluating Evidence in Medicine: What Can Go Wrong.” Among other things, I mentioned that acupuncture was a theatrical placebo. During the Q&A, I was challenged by a woman who insisted acupuncture had worked to cure her migraines and other symptoms. She was persistent and argumentative, determined to get me to agree that acupuncture did work. I finally told her it had been tested in large groups of people with controlled studies and shown not to work; if it didn’t work in those large controlled trials, why would it work for her? Maybe she was special? That got a laugh, even from her, but she kept trying to convince me that acupuncture really did work.
• The professor who invited me reported, “I’ve taught all five of my classes over the past two days, and in each, people had wonderful things to say about your presentation. Of course, many of them revolved around that ‘interesting’ woman who stood up during the Q&A to debate you about acupuncture, but again, my students took your side (i.e., the side of the evidence!), and simply expressed wonder at her persistence.”
• That was very encouraging. It showed that the students understood my message and were able to apply it. Acupuncture may be winning, but if we can educate the public about science and critical thinking, we might be able to reverse the trend. The Skeptical Inquirer is one effort in the right direction.

Dr Harriet Hall's argument is very logic and stands up. I don't think there is any one from acupuncture researcher community or clinical crowds who consider it is easy to repute Dr Hall's logic.

A “Placebo” That Is Most Evidence-Based

In 2012, British researchers (Mark Corbett et al, 2012) published the results of their systematic meta-analysis review, which compared the effectiveness of (TCM) acupuncture with other physical treatments for relieving chronic OA knee pain. The review analyzed 134 original trials which involved 18 interventions for OA knee pain including acupuncture:

• acupuncture (TCM),
• Balneotherapy,
• braces,
• aerobic exercise,
• exercise (muscle strengthening),
• heat treatment,
• ice/cooling treatment,
• insoles,
• interferential therapy,
• laser/light therapy,
• manual therapy,
• neuromuscular electrical stimulation (NMES),
• pulsed electrical stimulation (PES),
• pulsed electromagnetic fields (PEMF),
• static magnets,
• Tai Chi,
• transcutaneous electrical nerve stimulation (TENS), and
• weight loss.

Based on the results from 32 higher-quality trials, the most reliable and consistent therapeutic benefit for OA knee pain was demonstrated only for acupuncture and exercise, with the former being significantly superior to the latter. So, the best Evidence-Based therapy available today for knee pain is ACUPUNCTURE.

If acupuncture indeed a theatrical placebo, it will be as such which is the most evidence-based one at least for treating knee-related disorders.

An Unresolved Paradox & The Truth

The more evidence-based popularity, the stronger the ensuing skepticism – acupuncture is a paradox.

Dr Harriel Hall's critiques are irrefutable. Then is acupuncture really a theatrical placebo? Insofar as the results from at least 5000 randomly controlled acupuncture trials to date concerned, no one is able to make a clear-cut convincing argument refuting Dr Harrel Hall's claim that acupuncture is a theatrical placebo.

But the truth is simply on the contrary though no one today knows the truth. This is simply because the truth is deeply buried under the millennia of dust. The therapeutic effectiveness of acupuncture is tangible (and thousands times superior to all today's status quo tricks if performed correctly); the placebo effect of acupuncture is close to zero in comparison with all other types of healing modalities available in modern medicine.

This Newsletter - The Truth of Acupuncture Science: How A Jewel Ended Up A Quackish Stone in Acupuncture History – is trying to present the readers a clear big picture demonstrating what is the truth of acupuncture.

Epilogue

Harriet Hall (1945-2023), MD, passed away on Jan 11, 2023. She was widely known as the SkepDoc. Since 2006 she has penned the SkepDoc column for Skeptic, and produced numerous medical explainers, such as the Top 10 Things You Should Know About Alternative Medicine. For the James Randi Educational Foundation Dr. Hall produced a 10-part video series on “Science-Based Medicine” along with a 26-page downloadable course guide (skeptic.com).

Science will not advance without critiques and skeptics. I pay tribute to Dr Harriet Hall for her unremitting endeavor of trying to prevent science from contamination by quackeries.

References

David W. Miller, et al, Incorporating Acupuncture Into American Healthcare: Initiating a Discussion on Implementation Science, the Status of the Field, and Stakeholder Considerations. Global Advances in Integrative Medicine and Health 2021

Harriet Hall, Is Acupuncture Winning? Skeptic Inquirer, 2019 https://skepticalinquirer.org/2019/01/is-acupuncture-winning/

Helene M. Langevin?and?Peter M. Wayne, What Is the Point? The Problem with Acupuncture Research That No One Wants to Talk About. The Journal of Alternative and Complementary Medicine 2018 VOL. 24, NO. 3

Mark Corbett et al, Acupuncture and other physical treatments for the relief of chronic pain due to osteoarthritis of the knee: a systematic review and network meta-analysis, NIHR Report 40, 2012 Centre for Reviews and Dissemination, University of York

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