Acupuncturists: don’t be afraid of the placebo!

Critjcs of acupuncture always make much of the fact – and it is a fact – that clinical trials generally show little if any difference between so-called sham and real acupuncture. From this they conclude that acupuncture is “just a placebo”.But this statement conceals a lot and needs to be examined in more detail than is always done.

What is sham acupuncture?

So-called sham acupuncture often consists in inserting needles at “wrong” (non-acupuncture) points and/or penetrating only a short way, just below the skin. Another idea is to use a fake needle, in which a blunt probe recedes into the handle like a stage dagger. The trouble with all these techniques is that they all provide a stimulus to the nervous system; they are not neutral.

At most, therefore, they can compare more effective with less effective treatment. And they depend on the assumption that classic acupuncture points exist. That is, there are places in the body where a needle produces particular effects that would not be produced at a different site.

Many modern acupuncturists, of whom I am one, don’t accept the existence of acupuncture points in this sense. We therefore concede the critics’ case, at least in part; not that it makes no difference at all where a needle is inserted, but it doesn’t have to be done in the traditional way.

So are there any alternatives to sham? In a moment I shall suggest a couple, but first I want to take a moment to look at the placebo effect itself.

What is the placebo effect?

There seems to be a widespread idea that the placebo response is somehow unreal. It is supposed to depend on belief (probably untrue) and is not quite genuine in the way that the response to a drug is genuine. It’s “all in the mind”.

But if you think about it for a moment you will see that this can’t be right. It depends on the probably unspoken assumption that there is a ghostly mind hovering just outside the body and producing unreal effects by means of suggestion. But most scientifically minded people don’t accept this idea; they think of the mind as being a function of the brain. In a crude and probably misleading analogy, we could say that the brain is the hardware and the mind is the software.

On this view all mental phenomena are the result of brain activity. In that case the placebo effect depends on the brain and is quite as real as anything else the brain does. So even if acupuncture works partly at the mental level, this doesn’t mean that it doesn’t have a physiological basis.

At the same time we’d like to know more, and in fact there is a lot of evidence from other kinds of research to show that acupuncture has real effects. Here I shall mention two, which I discuss in separate posts. One is an interesting study carried out recently in Canada, and the other depends on the idea of using patients as their own controls.