Fact: The preponderance of current evidence indicates that traditional Chinese acupuncture is not more effective than a variety of sham acupuncture procedures in relieving low back pain or knee pain due to osteoarthritis.
Question: Is the striving for relief of pain via acupuncture the pursuit of a placebo effect?
The traditional definition of a placebo as treatment that is inert and lacks specific activity is being challenged because of the varied spectrum of placebo effects. Placebo effects such as the relief of pain result from a variety of factors, including the individual expectations, beliefs and desires of any given patient. So-called "contextual healing" is the facet of healing that is made manifest by the clinical encounter-a distinct and completely different entity from the efficacy of treatment interventions. In other words, the placebo effect is part and parcel of the doctor-patient relationship. The placebo effect vis-à-vis pain relief works through the activation of endogenous opioid and nonopioid control mechanisms, in addition to the modulation of central pain processing.
A patient's expectation of benefit contributes significantly to the efficacy of placebo treatments; this has been shown in several clinical studies of acupuncture. Several trials of traditional Chinese acupuncture and sham acupuncture for migraine, headache, chronic low back pain and osteoarthritis of the knee involved patients being queried as to whether they considered acupuncture to be an effective treatment, and what they expected from that treatment. Patients with high expectations fared better; however, they also benefited equally from acupuncture and sham acupuncture in terms of pain relief.
Of course, the efficacy of sham procedures has led some practitioners of traditional Chinese acupuncture to promulgate the theory that sham acupuncture is not a placebo because there are physiologic effects noted, for example, through the use of functional magnetic resonance imaging (MRI). Nonetheless, the students of the placebo effect counter that this logic goes against the large body of literature that concerns itself with the physiological effects of placebos and mind-body interactions.
It would certainly seem that acupuncture is a placebo effect, as most of the benefits from this result from the patient-provider interaction: thus, the definition of placebo effect is met.
The counseling of patients who request this placebo treatment should involve an explanation of the efficacy, the potential adverse effects, the cost, and the fact that it appears to be a placebo treatment. If it is not disclosed that acupuncture is a placebo treatment, then an ethical violation has occurred, despite any concomitant altruistic motivation. As there is a less than 50% chance of pain relief with acupuncture, I might be a little hesitant to recommend acupuncture for chronic pain.
Therefore, I would suggest to a patient requesting acupuncture a variety of other proven treatment modalities, all the while keeping available the option of acupuncture for those patients who fail or are intolerant of the typical medical treatments; and always explaining to the patient the lack of efficacy seen in the published acupuncture literature.
There is no need for deceit, even if it be offered with the most altruistic of motivations.
