INTEGRATIVE MEDICINE: The Role of Acupuncture in Modern Medical Practice

Martin L. Rossman, MD, Dipl Ac

When I first introduced acupuncture into my medical practice in 1972, there were no American training programs in Chinese medicine, no licensure, and very few practitioners. Now there are nearly 160 acupuncturists in Marin County (but only a few physician acupuncturists), licensure programs in almost every state, and 50 acupuncture colleges throughout the United States granting both master’s and doctoral degrees. Nationwide, approximately 12,000 acupuncturists, including an estimated 2,000 to 3,000 physician acupuncturists, are currently in practice.

According to the 2007 National Health Interview Survey, an estimated 3.2 million Americans had used acupuncture in the previous year. While pain is by far the most common complaint treated with acupuncture,[1,2] the procedure is also quite useful in clinical conditions as diverse as allergic rhinitis, asthma, COPD, carpal tunnel syndrome, dysmenorrhea, tendinitis, bursitis, and nausea from anesthesia, pregnancy or chemotherapy.[3-11]

In the early 1970s, as a young physician with many chronic-illness patients in my practice, I became frustrated with the limitations of my treatment options. In late 1971 our medical staff meeting featured a videotape made by the first AMA Blue Ribbon delegation to China after diplomatic relations were restored earlier that year. The video showed a patient having a pulmonary lobectomy with only a few subcutaneous acupuncture needles for anesthesia in his arms and legs. While the surgeon transected the patient’s ribs and lifted the diseased pulmonary segment out of his chest, the patient, fully conscious, was sipping tea and talking with the attending nurses. The head of the AMA delegation, Dr. Samuel Rosen, an eminent professor of surgery at Columbia, commented, “We saw a hundred such operations and cannot explain what we saw. We think that this phenomenon requires immediate and thorough investigation.”

I soon volunteered to help with the first major U.S. study of acupuncture for intractable-pain patients and saw with my own eyes that patients who had failed spinal tractotomies, multiple nerve blocks and intensive polypharmacy at the Mayo Clinic, University of Michigan and Case Western Reserve could often be helped with a course of 12-15 acupuncture treatments. At the end of three years, the authors reported significant help for 40-45% of them.[12]

In the intervening 40 years, both clinical and basic science research have helped us better understand how acupuncture works and the roles that acupuncture can play in medical practice. Humoral and neural mechanisms have been identified, and electromagnetic factors are now being studied. It has been well demonstrated that acupuncture analgesia is at least partially mediated by endorphins and enkephalins in the limbic system, midbrain and spinal cord. Research in China and Europe has also revealed that other neuroactive peptides--including serotonin, substance P and CCK--are involved with responses to acupuncture.[13,14]

While humoral mediators are the best-researched mechanisms, CNS and ANS mechanisms are also clearly involved. Melzack and Wall’s gate theory of pain is thought to explain part of acupuncture’s pain relief, whereby the non-painful stimulation of acupuncture stimulates fast myelinated A-delta fibers that inhibit the transmission of the larger, slower C-fiber signal in the ascending pain pathways of the spinal cord.[15] We now have over 750 fMRI studies showing that acupuncture alters pain transmission pathways in the cortex, thalamus and cingulate gyri; inhibits the recruitment of brain areas that amplify pain signals; and suppresses limbic and midbrain nuclei known to be involved with pain perception and transmission.[16]

Clinical acupuncture research is a problematic area because the “gold standard” double-blind, placebo-controlled clinical trial that works well for pharmaceuticals does not work well for procedural interventions like acupuncture. It is difficult if not impossible to design a true placebo control for acupuncture, and it is impossible to double-blind acupuncture studies. Patients and practitioners know whether or not points are being stimulated in spite of attempts to design a sham stimulation. To complicate matters, stimulation of non-acupuncture points on the skin has been shown to have significant analgesic effects.[17] This makes it difficult to demonstrate significant differences between verum and sham acupuncture, especially with the small sample sizes and inadequate duration typical of most Western acupuncture studies.

In spite of these research difficulties, an expert panel of 17 evaluators from academic medical institutions around the country convened by the National Institutes of Health in 1997 concluded that there was good quality evidence for acupuncture’s effectiveness in the many conditions mentioned earlier in this article.[3] They acknowledged the remarkable safety record of acupuncture and issued a call for more research in two dozen other conditions where the evidence indicated that acupuncture was likely to be effective.

As clinicians with patients in pain, or suffering from chronic illness, when should we think about referring for acupuncture? I think the bottom line is this: If a patient has a persistent pain problem unresponsive to relatively simple short-term and safe pharmacotherapy and doesn’t require immediate surgical intervention, it makes sense to refer them for a brief trial of acupuncture. It will help many of them and won’t harm those that it doesn’t help. If you refer a patient, have them return to you after six treatments for a re-evaluation. If they show improvement with frequency, intensity and tolerability of symptoms, or have been able to reduce analgesic or other medications, recommend that they have another six treatments and then follow up again.

If someone isn’t showing definite signs of improvement by six treatments, they have given acupuncture a fair trial, and it is appropriate to move on to another form of treatment that may help them more. If they are improving during the trial period, they usually will require a total of 9-15 acupuncture treatments over 3-4 months. Some patients will obtain long-lasting results, while others will require maintenance treatments at varying intervals, depending on the chronicity of their condition.

The nature of the condition is not the sole determining factor in whether acupuncture can help a patient. Each patient has an innate responsiveness that varies from non- to exquisitely responsive. In a highly responsive patient, we can often help in conditions that are not usually treated with acupuncture; but in a low-response patient, we may not be able to help with conditions that usually have high success rates. The six-session clinical trial will indicate whether or not pursuing treatment makes sense in any individual patient.

Acupuncture responsiveness is a biological trait. Sprague Dawley rats nonresponsive to acupuncture can be converted to responsive animals by administering cholecystokinin, an endorphin agonist.[18]

As with any other professional referral, a physician should get to know reliable, accountable sources for acupuncture. Physicians and patients alike are often more comfortable with a physician acupuncturist, especially when they have chronic, serious or complicated medical conditions. A physician acupuncturist is likely to better understand medical terms, conditions and pharmacological treatment, and may also be better able to communicate with referring physicians. Visits to physician acupuncturists may be reimbursable by insurance, especially if the treatments are part of a program encouraging patients to eat well, exercise within capacity and manage stress more effectively. My patients with PPO insurance average about 60% reimbursement on their charges, with some receiving 40% and others as much as 90%.

Wherever you refer, there is some measure of quality assurance by selecting board certified diplomates of the National Commission for the Certification of Acupuncture and Oriental Medicine (NCCAOM), which has set nationally accepted criteria for education, experience and ethical behavior of acupuncturists. The American Academy of Medical Acupuncture is another reliable source for selecting quality medical practitioners.

One of the important advantages of acupuncture as a therapy is its remarkable record of safety. In careful hands, using sterile, disposable needles (and there is NO reason to refer to an acupuncturist who does not use disposable needles), the risk is virtually nil. Reported adverse effects are extremely rare and predominantly consist of local infections around needle sites or temporary exacerbations of symptoms that rarely last over 24 hours and are often followed by improvement. While more serious complications (including pneumothorax and transmission of infectious disease) have been reported, these are truly rare. English and Norwegian studies indicate that an acupuncturist might cause one serious event in 100 years of full-time clinical practice, a safety margin that far exceeds the risk of prescribing analgesic medications or other interventional procedures.[19]

When acupuncture is more integrated into our system of medicine, it will be used much earlier in the evolution of pain and other disease syndromes, and we will have even better success than we do now. Patients should have a trial of acupuncture somewhere between taking intermittent and regular doses of analgesics or anti-inflammatories, and certainly before embarking on long-term use of narcotic analgesics or invasive procedures. Those we cannot help with this often effective and safe intervention can then consider riskier, more expensive and more invasive alternatives.

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Acupuncture and Weight Control

Research on acupuncture in weight control is mixed and confusing. On the one hand, acupuncture has been shown to alter levels of leptin, ghrelin, insulin and CCK, and helped increase weight loss when combined with low-calorie diet and exercise. Other studies have not shown the weight-loss effect. In my experience, acupuncture is a useful adjunct in the responsive patient (see main article). Placement of small metal pellets in appetite suppression points can help in early stages of weight loss. Ear stapling can cause infections and has never been demonstrated to be more effective than the non-penetrating pellets.

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Dr. Rossman practices integrative medicine and medical acupuncture in Greenbrae, and is on the clinical faculty at UCSF.

Website: www.drrossman.info

Phone: 415-925-8600

References

1. Bullock ML, et al, “Characteristics and complaints of patients seeking therapy at a hospital-based alternative medicine clinic,” J Alt Comp Med, 3:31-37 (1997).

2. Diehl DL, et al, “Use of acupuncture by American physicians,” J Alt Comp Med, 3:119-126 (1997).

3. Proceedings of NIH Consensus Development Conference on Acupuncture, November 3-5, 1997, Bethesda, MD.

4. Zhang BM, et al, “Acupuncture for chronic Achilles tendinopathy,” Chin J Integ Med, (Dec. 21, 2012).

5. Szczurko O, et al, “Naturopathic treatment of rotator cuff tendinitis among Canadian postal workers,” Arthritis Rheum, 61:1037-45 (2009).

6. Lathia AT, et al, “Efficacy of acupuncture as a treatment for chronic shoulder pain,” J Alt Comp Med, 15:613-618 (2009).

7. Brinkhaus B, et al, “Acupuncture in patients with seasonal allergic rhinitis,” Ann Int Med, 158:225-234 (2013).

8. Choi SM, et al, “A multicenter, randomized, controlled trial testing the effects of acupuncture on allergic rhinitis,” Allergy, 68:365-374 (2013).

9. Witt CM, et al, “Acupuncture in patients with dysmenorrhea,” Am J Ob Gyn, 198:166 (2008).

10. Yang YQ, et al, “Considerations for use of acupuncture as supplemental therapy for patients with allergic asthma,” Clin Rev Allergy Immun, 44:254-261 (2013).

11. Suzuki M, “A randomized, placebo-controlled trial of acupuncture in patients with chronic obstructive pulmonary disease,” Arch Int Med, 172:878-886 (2012).

12. Man PL, Chen CH, “Acupuncture for pain relief: a double-blind, self-controlled study,” Mich Med, 73:15-18 (1974).

12. Stux G, Pomeranz B, Basics of Acupuncture, Springer Verlag, (1995).

13. Lan L, et al, “Electroacupuncture exerts anti-inflammatory effects in cerebral ischemia-reperfusion injured rats via suppression of the TLR4/NF-κB pathway,” J Mol Med, 31:75-80 (2013).

14. Leung L, “Neurophysiological basis of acupuncture-induced analgesia,” J Acupunc Meridian Stud, 5:261-270 (2012).

15. Melzack R, Wall P, “Pain mechanisms: A new theory,” Science, 150:971-979 (1965).

16. Huang W, et al, “Characterizing acupuncture stimuli using brain imaging with fMRI,” PLoS One, 7(4):e32960 (2012).

17. Moffet HH, “Sham acupuncture may be as efficacious as true acupuncture,” J Alt Comp Med, 15:213-216 (2009).

18. Kim SK, et al, “Maintenance of individual differences in the sensitivity of acute and neuropathic pain behaviors to electroacupuncture in rats,” Brain Res Bull, 74:357-360 (2007).

19. Witt CM, et al, “Safety of acupuncture,” Forsch Komplementmed, 16:91-97 (2009).