Puncturing the myths?

Acupuncture is commonly used as a complementary therapy in the substance use field. But how effective is it, asks Natalie Davies.

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A recent essay published by Drug and Alcohol Findings asked whether acupuncture can treat acute substance use problems and disorders or relieve symptoms of withdrawal, and included a healthy dose of scepticism about whether acupuncture ‘works’ at all. No doubt some readers thought it went too far in its criticism of acupuncture, and others that it had not gone far enough to distance the practice from accepted evidence-based treatments.

Building on that essay, I want to explore how language may be blurring the lines between alternative and conventional treatments, and why resistance to acupuncture may be more an issue of ethical resistance to placebos, making acupuncture a topical vehicle through which to debate their use.

Traditional acupuncture has been developed over 2,000 years in China, Japan, and other East Asian countries. A self-regulated profession in the UK, traditional acupuncture is delivered outside the NHS alongside other alternative and complementary therapies. Western medical acupuncture, on the other hand, is sometimes available on the NHS but most often paid for privately, and delivered by medical practitioners such as doctors, physiotherapists and nurses as an add-on to their conventional professional practice.

The NHS Choices website doesn’t equate acupuncture with conventional treatment, but does distinguish ‘Western medical acupuncture’ from ‘non-medical acupuncture’ or ‘traditional Chinese medicine acupuncture’ – the first at least sounding more like a conventional treatment. Allied with this is the medical language explaining how it works and the stipulation that Western medical acupuncture is used following a medical diagnosis.

Traditional acupuncture is based on the idea that problems with our health and wellbeing can surface when vital energy known as Qi (pronounced ‘chee’) is prevented from flowing freely throughout the body, and works by restoring the flow of this so-called ‘life force’. In contrast, Western medical acupuncture reincarnates acupuncture as a procedure that stimulates sensory nerves (as opposed to ‘energy’) under the skin and in muscles, causing the body to produce endorphins and other naturally-occurring chemicals.

Acupuncture adherents cite the benefits of treating the person not the condition, and claim in doing so that acupuncture can not only maintain good health and prevent bad health, but improve one’s overall sense of wellbeing. For people so inclined, the gentle insertion of hair-thin, flexible needles is reported to be relaxing, and at the site of the needles is sometimes associated with pain-free feelings of heaviness, aching, tingling and warmth.

For the NHS, acupuncture is currently only recommended for chronic tension-type headaches and migraines, but is also used to treat other types of pain. In the substance use field acupuncture has been a popular alternative treatment for people with cocaine use problems – though this may have had more to do with the lack of an accepted conventional treatment than the particular merits of acupuncture, and the need for acupuncture itself may be illusory as just about any psychosocial therapy helps some of these clients some of the time.

A 2006 assessment from the respected Cochrane collaboration of whether acupuncture at sites on the ear has helped in the treatment of cocaine dependence found definitively that, ‘There is currently no evidence that auricular acupuncture is effective for the treatment of cocaine dependence’. As evidence was limited and from methodologically poor studies, the assessment stopped short of saying that acupuncture was ineffective. Across the spectrum and range of substance use issues, the same or similar conclusions apply.

It could be argued that offering something concrete like acupuncture which both clients and staff believe to be worthwhile might aid a person’s recovery by attracting them to services, and – as some studies have suggested – helping to retain them in treatment. However, the defence of acupuncture in the absence of evidence of effectiveness would then almost certainly take us into the territory of ‘placebos’ – inert procedures wrapped up as medical treatments that may exert an effect, but only to the extent that patients expect or believe they will have an effect.

Any of the perceived ethical ambiguity of placebos was stripped out by a commentary published in the American Journal of Bioethics by Dr Alain Braillon, an alcohol treatment specialist in France. Disputing their ‘benign’ connotations, Braillon argued that placebos fundamentally compromise the precious relationship between doctor and patient, ‘strengthen medical arrogance’, ‘infantilise people’, and ‘can delay the proper diagnosis of a serious medical condition’. As he saw it, placebos were ultimately a lie.

Not coming down so harshly on placebos, the NHS website at one time reminded readers in the context of alternative and complementary therapies that ‘for many health conditions, there are treatments that work better than placebos […and by choosing] a treatment that only provides a placebo effect, [the patient] will miss out on the benefit that a better treatment would provide’. However, it stated ‘improvement in a health condition due to the placebo effect is still improvement, and that is always welcome’. Interestingly, in the last few months these comments appear to have been removed.

Although acupuncture specifically has drawn protestations of ‘sham procedure’ and ‘theatrical placebo’, it has also been able to elicit a certain generosity of hope of the type that may be reserved for interventions of a transcendental nature. Furthermore, as it has fallen between the gaps of alternative and conventional therapies for treating health conditions, whether delivered in a high street clinic or mainstream healthcare space, patients absorbing the cues of the environment and culture may have found themselves yielding to something which at once seems a legitimate medical treatment and an ancient form of healing.

Shu-Ming Wang and colleagues wrote in Anesthesia and Analgesia that ‘Instead of criticizing [the] ancient art [of acupuncture] with arguments culled from modern medicine and science, physicians and scientists should try to integrate current knowledge into this ancient, yet ever-evolving practice so it may be used to treat conditions for which pharmaceutical interventions are ineffective and/or potentially dangerous’.

Perhaps instead of removing acupuncture from the ambit of science as this comment suggested, it could be incorporated within the ‘common factors’ framework as a vehicle for delivering the essence of an effective psychosocial therapy – a credible procedure which offers an explanation for the patient’s condition and a credible remedy that the patient believes in, delivered in a context which gives it the aura of a bona fide clinical treatment.

If there is not so much a ‘lie’ as a false impression at the heart of acupuncture, it may be that it is presented as a physical treatment rather than vehicle for the common factors found in psychosocial therapies. But without that sincerely held conviction, those common factors would be undermined and with them any benefit to be gained.

Natalie Davies is co-editor of Drug and Alcohol Findings

Read more in Findings on acupuncture here

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