Original Article: Acupuncture for Pain; and Integrating Medical Acupuncture into Family Medicine Practice [Editorial]

Issue Date: July 15, 2019

See additional reader comments at: https://www.aafp.org/afp/2019/0715/p89.html and https://www.aafp.org/afp/2019/0715/p76.html

To the Editor: I am writing in regard to this article and its accompanying editorial. Both advocate for the use of acupuncture in family practice and training of physicians based on weak evidence. The authors of the editorial anecdotally report they have seen skeptical physicians change their minds about acupuncture during training.

Seeking to validate their beliefs, proponents of acupuncture tend to cherry-pick the weak but positive studies and ignore the negative ones. However, larger blinded studies show no significant difference in pain relief from acupuncture compared with sham acupuncture.^1–3

The article states, “Traditionally, acupuncture is thought to restore the normal flow of energy (qi) in the body.” This is typical of pseudoscientific jargon based on the belief in mystical, unmeasurable “vital energies” akin to the “psora” of homeopathy or the “life force energy” of chiropractic. They also state that acupuncture is safe, ignoring incidents of pneumothorax and infection.^4–6

Acupuncture is therefore based on weak scientific evidence; claims of ancient knowledge; unproven, invisible forces; and anecdotes, and only works when sold to the patient with reassuring words and hand-holding. What our patients are actually looking for is someone who will take the time to listen to them, establish trust, and show empathy. When we fall back on smoke and mirrors just to “do something,” we betray that trust.

Let's not go back to the days of bloodletting and phrenology. You can do better than this, American Family Physician.

In Reply: Rather than cherry-picking positive studies and ignoring negative ones, we restricted our evidence review to meta-analyses and systematic reviews of multiple randomized controlled trials. Our quantitative outcome comparisons and Strength of Recommendation Taxonomy (SORT) table provided the reader with information on the size of treatment effects and the strength of the evidence for clinical recommendations. We also specifically mentioned the possibility of pneumothorax and serious infection as rare adverse effects of acupuncture, despite its very good safety record overall. I agree with Dr. Kann that patients appreciate a physician who listens and establishes trust, although this goal in no way excludes considering and proposing the option of a trial of acupuncture for selected patients with painful conditions.

In Reply: Thank you for the questions about evidence-based practice and how we investigate clinical questions with multimethods work. Like research on any procedure, acupuncture research is limited by the inability to perform completely blinded placebo procedures. New procedures for appendectomy or laceration repair are not evaluated against placebo treatment—they are evaluated against the standard of care. Although considerable effort has been expended to create placebo acupuncture devices, savvy patients are still able to tell the difference; therefore, expecting double-blind placebo in acupuncture research is typically unreasonable. Researchers should attempt to blind the evaluator (i.e., the person asking about pain or administering questionnaires) because neither patients nor treating physicians can be blinded to the treatment.

Placebo acupuncture has up to a 41% effectiveness rate,¹ which is possibly attributable to what Dr. Kann calls “reassuring words and hand-holding.” This placebo response is comparable with drug trials in which patients assigned to placebo groups also experience positive treatment outcomes.² Still, studies demonstrate true acupuncture is superior to sham or placebo acupuncture.¹

The editorial we wrote is derived from a rigorous program of qualitative research that we conducted with physicians who practice acupuncture and patients who have received the treatment.^3–5 Rather than anecdotes, which are stories that stand alone to make a point, these findings are based on empiric, qualitative research. Specifically, our research draws from semistructured interviews that capture both patients' and physicians' experiences. “Within the context of a qualitative research project, an anecdote does not exist.”⁶ Quotes presented in the study are data and provide exemplar representations of phenomena identified across participants, thereby indicating a pattern of experience, as opposed to a single case, as one might see in a news article portraying one person's story. The scientific articles presenting this research included patients describing benefits of receiving acupuncture, as well as patients not experiencing benefits.

We agree that listening and creating trust are key elements of being a physician. Not only was the role of communication a key finding in our work, but patients and physicians reported that acupuncture helped cultivate a more open, trusting clinical relationship.⁴

The authors thank Carla Fisher, PhD, our qualitative research expert, who reviewed an early draft of this letter reply and recommended content changes and improvements.

The opinions and assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the U.S. Air Force, the Uniformed Services University of the Health Sciences, or the Department of Defense at large.