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ACUPUNCTURE: THERAPY OR HUMBUG?

By Edward A. Hemmingsen

"Acupuncture is a component of he health care system of China that can be traced back for at least 2,500 years. The general theory of acupuncture is based on the premise that there are patterns of energy flow (Qi) through the body that are essential for health. Disruptions of this flow are believed to be responsible for disease. The acupuncturist can correct imbalances of flow at identifiable points close to the skin."

These are the opening lines of a Consensus Development Statement issued by a panel convened by the National Institutes of Health on acupuncture from November 3-5, 1997. In the associated news release, regurgitated in the mass media, the panel chairman adds: "The challenge in studying acupuncture is to integrate the theory of Chinese medicine into the conventional Western biomedical research model and into the conventional health care arena."

But does acupuncture work? The news release states that "there is clear evidence that needle acupuncture treatment is effective for postoperative and chemotherapy nausea and vomiting, nausea of pregnancy, and postoperative dental pain" but that "there is less convincing scientific data" that acupuncture is effective for the treatment of other conditions such as addiction, headache, fibromyalgia, low back pain, and asthma.

The Consensus Statement itself is somewhat more cautious than the news release. It states: "According to contemporary research standards, there is a paucity of high-quality research assessing efficacy of acupuncture compared with placebo or sham acupuncture. The vast majority of papers studying acupuncture in the biomedical literature consist of case reports, case series, or intervention studies with designs inadequate to assess efficacy." It goes on to state that "some individuals are poor responders to specific acupuncture protocols. Both animal and human laboratory and clinical experience suggest that the majority of subjects respond to acupuncture, with a minority not responding. Some of the clinical research outcomes, however, suggest that a larger percentage may not respond. The reason for this paradox is unclear and may reflect the current state of research."

Another hint of difficulties is given in the statement on placebos or sham acupuncture. "A commonly used control group is sham acupuncture, using techniques that are not intended to stimulate known acupuncture points. However, there is disagreement on correct needle placement. Also, particularly in the studies on pain, sham acupuncture often seems to have either intermediate effects between the placebo and 'real' acupuncture points or effects similar to those of the 'real' acupuncture points. Placement of a needle in any position elicits a biological response that complicates the interpretation of studies involving sham acupuncture. Thus, there is substantial controversy over the use of sham acupuncture as control groups. This may be less of a problem in studies not involving pain."

On the assumption that acupuncture works, the Consensus Statement proceeds to speculate on how it works. It suggests, among other factors, that release of opioids, activation of the hypothalamus and the pituitary gland, or alterations in the secretion of neurotransmitters and neurohormones may play a role. It mentions that studies showing such changes exist.

The old Chinese acupuncture theories are neither dismissed nor accepted. It is not mentioned that acupuncture was banned in China in 1929, and revived during the cultural revolution in the 1960s. "Even more elusive is the scientific basis of some of the key traditional Eastern medical concepts such as the circulation of Qi, the meridian system, and the five phases theory, which are difficult to reconcile with contemporary biomedical information but continue to play an important role in the evaluation of patients and the formulation of treatment in acupuncture."

For someone looking for a scientific, or at least an independent, objective assessment of acupuncture, the consensus statement is a great disappointment. It is riddled with ambiguities, vague and inconsistent statements, and broad generalizations that appear to have no basis in fact. It also misleads. For example, it states that ". . . U.S. Food and Drug Administration recently removed acupuncture needles from the category of 'experimental medical devices' and now regulates them just as it does other devices, such as surgical scalpels and hypodermic syringes . . ." What the FDA actually states is: "In response to petitions submitted by the acupuncture community, FDA has reclassified acupuncture needles for general use from Class III, a category in which clinical studies are required to establish safety and effectiveness, to Class II, a category which involves less stringent controls by FDA but requires good manufacturing and proper labeling.

The conclusions of the consensus panel have not gone unchallenged. A number of medical scientist, including members of the National Council Against Health Fraud, who have been interviewed by the press have expressed strong skepticism of the research presented at the conference, and the conclusions drawn by the panel. Critics have pointed out that the best designed experiments produced the poorest evidence for the effectiveness of acupuncture, whereas the poorly designed experiments produced the best evidence. The independence and objectivity of the panel may be questioned. The panel had no medical representatives from the skeptical community but had representatives of practitioners and promoters of the procedure. A similar imbalance can be found in the list of speakers invited to give presentations to the panel; believers and others who have a stake in the acceptance of acupuncture are well represented.

This may not be surprising. The panel was convened under the auspices of the Office of Alternative Medicine, which sponsors research on so-called alternative medicine, ranging from the benefits of meditation to "touch therapy," in which the patients are not touched, but rather ìenergy fieldsî hovering above the body are manipulated. This research has been criticized by mainstream scientists who find that these therapies are not investigated with the same rigor as more conventional ones. The Office of Alternative Medicine was formed in 1992 through the efforts of Senator Tom Harkin (Democrat, Iowa), a strong believer in alternative medicine. He has labeled several pre-eminent scientists in the country, who have questioned the Office's research designs, as not qualified to do so because they lack backgrounds in alternative medicine.

Clearly, we are not yet at a point where we know whether or not acupuncture works. Short of quackery, it may be one of the many types of stimuli that trigger the release of pain-reducing endorphins, which are narcotic-like substances produced by the body. Or it may stimulate a simple placebo effect which either diverts attention from a symptom to another part of the body; or it may trigger certain psychological mechanisms and alter subjective perceptions.

Presumably, there will be a formal, more detailed science oriented report forthcoming from the acupuncture conference. Such a report may give us some better insight into the panel's conclusions. In the meantime, the NIH Consensus Statement has provided some legitimacy to acupuncture that appears not to be deserved.

What is next? Homeopathy? Therapeutic Touch? Magnet Therapy? Stay tuned; tax money at work!

Sources consulted:

The National Institutes of Health Consensus Development Statement on Acupuncture, Nov. 3-5, 1997, revised draft, 11/5/97. Avail able at http://odp.od.nih.gov/consensus/ statements/cdc/107/107_stmt.html

The National Institutes of Health News Release, Nov. 5,1997. Available at http://www.nih.gov/news/pr/nov97/od-05.htm

The Food and Drug Administration announcement, April 1, 1996, Acupuncture Needle Status Changed. Available through their Web Home Page at http://www.fda.gov On "Search" submenu, select "Talk Papers" and "Center for Devices and Radiological Health", and search term "acupunture".

National Council on Health Fraud Position Paper on Acupuncture. Available at http://www.hcrc.org/ncahf/pos-pap/acupunct.html

The Chronicle of Higher Education, July 11, 1997, page A27.

The Scientist, November, 10, 1997, page 7.

Time Magazine, November 17, 1997, page 84.

San Diego Union-Tribune, December 30, 1997, page C-1.

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Edward A. Hemmingsen is an Emeritus Physiologist at UCSD and the Editor of Rational Inquiry.