Rational Prescribing Article Series

Article 4: Does Acupuncture Work? Rational Prescribing Meets Evidence-Based Medicine

As a medical doctor who treats chronic pain, I do a lot of acupuncture. If you are a doctor, a researcher or a layperson guided by science, your first question might be “what is the evidence for that?” While this may seem like a valid question, it is a bit misguided, and the answer is not as important as you might think. To find out whether acupuncture or any other therapy might help you, a rational prescribing approach makes more sense.

The Musician and Their Instrument

The first problem with questions like “is it proven to work” is that while acupuncture is a treatment tool, the music that is made during an acupuncture session depends more on the musician than their instrument. This is true not only for acupuncture, but also for massage therapy, spinal manipulation, physiotherapy or any other treatment that is administered by a person. The treatment that they provide depends on their skill, their experience and on what they choose to do for you on that particular day.

An acupuncturist’s diagnosis might be based on a clinical history, an assessment of the affected area, an examination of the pulse, the tongue or other specific techniques. They may take into account certain specific lifestyle factors, or mental and emotional stressors, both those affecting you now and those that have shaped you in the past. The rapport between patient and provider might be relaxed and easy, or tense and awkward.

The treatment itself might involve a single needle, or half a dozen, or two dozen. The points selected might be based on a Traditional Chinese Medicine diagnosis of blockages and imbalances in blood or qi, or a medical acupuncture approach that targets the musculoskeletal system and related connective tissue.

Needle insertion might be quick and simple, or slow and purposeful, with concentrated attention from the practitioner. Needles can be inserted to varying depths, they can be twisted back and forth to create something called a “de qi” sensation, and they can be connected to machines that deliver electrical current to the tissue. These needles might be inserted in body points, or in microsystem points in the ear, the hand, the scalp or other areas.

Evidence: Think Globally and Act Locally

All of these factors can affect how acupuncture affects the body. Dozens of experiments have confirmed that acupuncture is a stimulus that triggers changes in nerves, the spine and the brain, and alters levels of several hormones and immune markers. Hundreds of clinical trials have evaluated acupuncture in many different conditions, and the outcomes of these trials can seem conflicting or confusing.

If you are seeking effective wellness solutions, whether your goal is to treat a specific condition, or for overall wellness and prevention, you should consider a rational prescribing approach. That means trying one thing at a time, and deciding for yourself whether it made a difference or not.

When it comes to natural health products, like herbs, vitamins and other supplements, different formulations can yield different results, so it is important to ensure that you choose the right product. In the same way, it is important to remember that a trial of acupuncture is actually a trial of one particular approach delivered by one particular person

Evidence-Based Medicine Is A Work in Progress

These factors make it very difficult to measure the effectiveness of acupuncture, because no two treatments are alike. This is unlike pharmaceutical drugs, which can be mass-produced to make millions of tablets or capsules, all identical in size, shape and colour, all containing exactly the same ingredients in identical amounts.

Evidence-based medicine is the system that the world uses to evaluate medical treatment. It was created in the early 1980s by David Sackett and his colleagues at McMaster University in Canada, and later exported to the world. They developed protocols for how to design and conduct randomized controlled trials and other kinds of clinical research studies.

The goal was to determine which treatments work and which don’t. But the system was designed based on a number of assumptions, some of which are simply false. And we learned many lessons along the way. Evidence-based medicine is a work in progress, and these lessons point to problems with the paradigm that we need to address as a society.

We learned over time that negative trials don’t get published, so trial registries were developed to address this problem. Trials must be registered when they begin so that they can’t be buried, and top journals don’t publish trials that were not registered.

We learned that the placebo response, which for acupuncture involves very superficial needling of real acupoints or regular needling of “non-acupoints” is not a real placebo. The placebo response is the reason that trials include control groups who don’t get the treatment being studied. A placebo pill can certainly be made to look and feel like the real thing, but what is a placebo manual therapy session?

We learned that studies can only be combined if the treatment is identical in every study, and this is nearly impossible with non-drug treatments. If a company owns a drug, every study they are involved in will use it in the specific dose and frequency that are recommended by the manufacturer. But therapists administering non-drug treatment are much harder to standardize.

And of course, funding and institutional pressures affect what researchers decide to study in the first place. These factors, and others, make me worry that evidence-based medicine might be like a pied piper that is leading us towards a future in which the only proven treatments are patented pharmaceutical drugs. Healthcare will always need big pharma to invest in research and innovation, but we need to create a space for evidence-based integrative healthcare.

How to Structure a Trial of Acupuncture

Before using acupuncture to treat a specific condition or problem, it is prudent to use proven treatments first. A proper assessment can help confirm your diagnosis and rule out serious diseases that might be causing your symptoms. If there are effective treatments that are supported by evidence and recommended in published guidelines, you should consider using them first. While some people who seek natural healing solutions can be skeptical of pharmaceutical drugs in general, every drug is different, and many are exceptional healing tools.

The principle of rational prescribing is simple and intuitive. The World Health Organization (WHO) says the rational use of medicines requires that “patients receive medications appropriate to their clinical needs, in doses that meet their own individual requirements, for an adequate period of time, and at the lowest cost to them and their community.” The approach is simple, and I have outlined it in this article (insert link) in the rational prescribing series.

If you have identified an acupuncturist that you feel confident about, you can structure a trial with them. But if your doctor is open to discussing these approaches with you, they are the ideal provider to help you structure your trial.

Clarify your treatment goal. Whether you are looking to improve migraines, sleep, irritable bowel syndrome or knee pain, clarify what a meaningful improvement looks like. An example might be a 50 percent reduction in headache days per month.

Next, define the course of treatment that makes sense to commit to for a trial. I typically recommend twelve sessions, twice per week in most cases, although this might differ for you based on your condition, your schedule and other factors.

Do the treatment diligently, follow your practitioner’s advice about what to do before and after each session to support the treatment. If you can’t stick with a consistent schedule, or some outside factor affects how you might benefit from it, keep this in mind for the next step.

When your trial is complete, sit down with your doctor or your acupuncturist and decide whether there was a meaningful improvement or not. This is not always an objective decision, and it is up to you to decide whether your results were meaningful or not. If it was helpful, keep doing it, perhaps reducing the frequency of visits gradually over time. If not, either find a new regimen or a new provider, or something other than acupuncture.

Your Data-Driven Healing Journey

When evidence-based treatment does not deliver the benefits you need and expect, it makes sense to explore other options. Taking these one at a time — assessing what works and what doesn’t — is a rational prescribing approach that makes good sense. While it is not for everyone, structuring your healing journey into a series of trials will allow you to build your self-care and wellness regimen over time, and this should include a roster of providers who have demonstrated that they can help you.

Mobile technology can be used to collect data on your healing journey. You can do it on your own, but mobile data systems are converging with wearable sensors, AI and machine learning to create the next generation of evidence-based medicine. This data can support clinical trials by providing accurate information about real-world effectiveness research. This might be how integrative medicine fits into evidence-based healthcare.