Acupuncture the Best Placebo Ever

Acupuncture has been practiced and refined for over one thousand years. Even so, one question still seems to get asked more than almost any other:

Is Acupuncture a placebo?

Now the short answer is no. Of course, I expect better of you than to just take my word for it. I should be clear, that when I say "no, acupuncture is not a placebo" I mean it the same way physicians mean that "morphine is not a placebo." Even though some of the effect of morphine is due to placebo; this has been recognized since at least 1955 (Beecher, p. 1606). But hospitals and emergency departments aren't rushing to replace their morphine supplies with normal saline, nor should they!

For those that don't know, the placebo effect is an effect, usually positive, of treatment that cannot be attributed to the physical components or chemical action of the treatment. The common example given is that of a sugar pill having the same therapeutic effect as a drug. Even proven effective treatments owe some of their effectiveness to the placebo effect (Munnangi & Angus, 2019). When the effect is negative, or counter to therapeutic effect, it is sometimes called the nocebo effect.

In order to evaluate the action of a proposed treatment, researchers will often compare the effect of a treatment to a control group that receives a placebo treatment (Munnangi & Angus, 2019). If the treatment performs better than the placebo treatment then the treatment is judged to be effective; that its effect is not only due to the placebo effect. This is what we mean when we say morphine is not a placebo treatment for pain; it is the same meaning when I sated above that acupuncture is not a placebo. Unfortunately it is difficult, maybe impossible, to give a placebo treatment to compare acupuncture with. Unlike with morphine, where inert saline can be used, any form of placebo acupuncture, sometimes called sham acupuncture, is likely to have some of the physiological effect of real acupuncture.

If there is no good way to test acupuncture against a placebo control, then how can we ever prove it to be not a placebo? Is such a thing possible? Of course it is! Scientific method to the rescue! A good hypothesis is falsifiable that is it makes predictions that can be tested. So what predictions can we make if acupuncture were a placebo? For example, would we expect it to work in animals? Indeed, acupuncture effectiveness in animals would strongly contradict our hypothesis of it being a placebo. However:

Animal studies have been instrumental in determining the effectiveness of acupuncture, as they are not subject to the same placebo effects as human subjects.(Magden, 2017, p. 56)

Magden (2017) references treatments in primates where heart arrhythmias were treated with acupuncture. While it's possible that pain might be subject to placebo effect in animals because the animal knows the practitioner is trying to help it; it is very unlikely that a primate knows a needle in its wrist is supposed to help a heart condition.

Some are, no doubt, not convinced by acupuncture in animal trials. How else could we see if acupuncture is a placebo? What if we compared its effects/results to something we already know is not a placebo? What about morphine? Well, that's exactly what researchers in Tunisia did. They found acupuncture relieved pain in more patients and slightly faster than IV morphine (Grissa et al., 2016). That study probably deserves its own blog post, but I'll just state the conclusion here:

Our study demonstrated that in patients with acute pain syndromes presenting to the ED, acupuncture is at least as efficacious and has a better safety profile than IV morphine (Grissa et al., 2016).

We could study this for twenty years even doing our own experiments to try and prove that acupuncture is a placebo. If we did, we'd end up with the same conclusion Bruce Pomeranz, PhD did in 1996. He began thinking that acupuncture was a hoax or a placebo at best, because that's what his mentor thought. However he did experiments on anesthetized animals and got a response from acupuncture; doesn't sound like a placebo to me! Dr Pomeranz was the first to publish results showing that acupuncture's pain relief is because it stimulates the release of endorphins, hormones produced by the body that bind the same receptors that drugs like morphine do; and that cause the same type of pain relief.

...we have more evidence in favor of the acupuncture-endorphin hypothesis than we have for 95% of conventional medicine (Horrigan, 1996)

I encourage you to read the entire interview with Dr Pomeranz, because he discusses other aspects of so called "alternative medicine" and I think it is worth your time. He is a scientist first, and a proponent of acupuncture research only secondarily. One of the marks of a true scientist is being willing to change your ideas, which some may call beliefs, when presented with evidence to the contrary. The next time that someone tells you acupuncture is a placebo, ask them sincerely what evidence it would take to change their mind. If no amount or quality of evidence is sufficient to change their belief, then they are not relying on science but superstition and stubbornness. In closing, I leave you with the words of one of my teachers:

Anyone who says that acupuncture is a placebo understands neither acupuncture nor the placebo effect.

References

Beecher, H. K. (1955). The powerful placebo. Journal of the American Medical Association, 159(17), 1602. doi:10.1001/jama.1955.02960340022006

Grissa, M. H., Baccouche, H., Boubaker, H., Beltaief, K., Bzeouich, N., Fredj, N., … Nouira, S. (2016). Acupuncture vs intravenous morphine in the management of acute pain in the ED. The American Journal of Emergency Medicine, 34(11), 2112-2116. doi:10.1016/j.ajem.2016.07.028

Horrigan, B. (1996). Bruce Pomeranz, PhD acupuncture and the raison d'etre for alternative medicine. Alternative Therapies in Health and Medicine, 2(6), 85-91. Retrieved from http://www.alternative-therapies.com Republished at: https://www.medicalacupuncture.org/For-Patients/Articles-By-Physicians-About-Acupuncture/Alternative-Medicine-Does-it-work-and-how

Magden, E. R. (2017). Spotlight on acupuncture in laboratory animal medicine. Veterinary Medicine: Research and Reports, Volume 8, 53-58. doi:10.2147/vmrr.s125609

Munnangi, S., & Angus, L. D. (2019, March 23). Placebo effect In: StatPearls [Internet]. Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK513296/