In 1986, the World Health Organization (WHO) released a new visual guide for pain management known as the “pain ladder.” Each rung on the ladder represented a different set of pain medications. On the bottom rung were over-the-counter medications like Tylenol, while opioids like morphine appeared closer to the top. It was a simple, stepwise rubric to help physicians’ streamline their approach to helping patients in pain.
The ladder was a big hit. It started cropping up in cancer treatment centers and pain clinics all over the world. Thirty years later, it’s still the go-to blueprint for basic pain management. But from one rung to the next, the ladder is unapologetically pharmacentric. It lacks any psychological, rehabilitative, or “natural” therapies for pain.
As an emergency doctor, I routinely see patients who have come to the emergency room (ER) seeking relief from chronic pain. Patients with fibromyalgia, osteoarthritis, chronic back pain, neuropathic pain—the list goes on. Pain is one of the most common reasons patients come to the ER. Yet, we as doctors are notoriously poor at managing it. We undertreat it, sometimes sending patients home from the hospital when they’re still very uncomfortable, even to the point of being unable to perform important daily tasks like cooking and cleaning.
More recently, the pendulum has swung the other way, and there’s been a trend to over treat pain, as evidenced by dangerously high numbers of opiate prescriptions in Canada and the United States. In 2015, Dr. Steve Morgan at the University of British Columbia showed that higher prescription rates for opiates are linked to higher rates of opiate-related overdose and death. Given that “do no harm” is one of the guiding principles of medicine, we need to seriously rethink our prescribing patterns.
If there’s a safer way to manage pain, shouldn’t we be trying it?
Throughout my medical career, I had often heard of acupuncture as an alternative treatment for pain, but I had dismissed it. If there was any merit to it, I reasoned, then I would have learned about it in medical school. But I also knew that my patients deserved an effort on my part to find an alternative to opioids.
For some time, I’d experienced intermittent pain from an old shoulder injury, something I’d typically treat with a few Tylenol. It occurred to me that perhaps I could look into acupuncture, not only for my benefit, but for my patients as well.
Acupuncture as placebo
Wellness blogs and alternative health gurus have long espoused the efficacy of acupuncture as a treatment for pain. And for decades, research groups have tested those beliefs. Some of these studies have even assigned patients to “sham” acupuncture treatments to control for the placebo effect. Results of individual studies have been inconsistent. Some showed a clear benefit from acupuncture, while others show no difference between acupuncture, sham procedures, and no treatment at all. With so much variability in the results, the medical community turned to meta-analyses (that is, retrospective studies of studies) for the final verdict. With a few exceptions, these more robust meta-analyses showed no benefit from acupuncture, prompting the International Anesthesia Research Society to publish an article in 2013 titled “Acupuncture Is Theatrical Placebo.”
“When no effective treatment exists for a medical problem, it leads to a tendency to clutch at straws,” explained Drs. David Colquhoun and Steven Novella, the authors of the paper. “Research has shown that acupuncture is little more than such a straw.”
The paper’s findings have not stopped scientists and alternative healers from their quest to vindicate acupuncture as a useful treatment for pain, particularly as the opioid crisis has worsened in America. In October, when president Donald Trump’s administration declared the crisis a national emergency, the National Certification Commission for Acupuncture and Oriental Medicine (NCCAOM) canvassed Trump to include acupuncture as a part of the solution. In an effort to encourage healthcare providers to choose alternatives to opioids, the National Association of Attorneys General submitted a letter, signed by 37 state and territorial attorneys general, requesting that America’s Health Insurance Plans review their payment and coverage policies.
In 2017, an Australian research group led by Dr. Marc Cohen published a study suggesting that acupuncture is as effective as Tylenol, non-steroidal anti-inflammatory drugs (NSAIDs), and even some opiates for the treatment of lower back pain and ankle sprains in the ER. Cohen and his team concluded that acupuncture is “a safe and acceptable form of acute analgesia…(and that) it may be useful as an adjunct to pharmacotherapy or when pharmacotherapy is unsuitable.”
Back in Toronto, Canada, where I work in the ER, it’s commonplace for patients to request narcotics for their pain. Last week I saw two patients who prodded me for more drugs. “I’m already taking percs (Percocets) for my back,” they told me, “but they’re not working any more. Can’t you write me a new prescription?”
I sent them home empty-handed. One of them told me I wasn’t doing my job. I was frustrated. Treating patients’ pain sometimes felt like hitting a tennis ball over a net knowing it was just going to get lobbed back at me the next moment.
I was intrigued by the possibilities of acupuncture as an alternative, but uncomfortable recommending it to my patients, as it was outside the scope of my medical training. I was also concerned by the design and methodological issues of some pro-acupuncture studies, which made their conclusions less compelling. It was time to gain more insight into the world of alternative medicine. I picked up the phone and booked an acupuncture appointment.
Needles in the nude
A few days later, I stood barefoot next to a waist-high padded table lined with a white sheet. A stack of neatly folded towels sat on a wooden chair in the corner. The room was dark, and my eyes needed a moment to adjust to the light.
A man’s voice came from just beyond a curtain that hung from small pegs in the ceiling.
“You can take your clothes off now, I’ll be back in a minute.”
It was my first time in an acupuncture clinic. I was nervous. I felt vulnerable, intimidated by the disparity between his knowledge of acupuncture and my own.
“This must be how my patients feel,” I thought.
Acupuncturists insert thin needles into the skin to stimulate points on the body to achieve a variety of different ends. Lying in the dark, moments away from my first acupuncture session, questions floated through my mind. Would it hurt? Are the needles clean? What if they accidentally puncture my lung? Infections and lung punctures are exceedingly rare complications from acupuncture, and are not something patients should worry about if they’re in a reputable, licensed clinic. I knew this, but worries drifted through my mind despite myself.
My acupuncturist shuffled back into the room.
“Where do you have pain?” he asked.
“My left shoulder,” I said. “Usually just after I wake up in the morning.”
“Do you have anxiety?”
“Do you have trouble sleeping?”
“Any liver problems? Do you get angry?” he asked.
“No to the liver problems,” I replied. “Yes to getting angry, sometimes.”
“The anger is related to your liver,” he said.
My anger is related to my liver? I must have missed that lecture in medical school. For the moment, though, I put this out of mind, suspending disbelief as the acupuncturist began inserting needles into my scalp, forehead, torso, legs, and feet.
Past and present
The first document outlining an organized system of acupuncture dates to 100 BCE in China. But some archeological findings—including sharpened pieces of bone and rock—suggest it may have even been in use as early as 6000 BCE. Practitioners of Chinese medicine believe that acupuncture modifies the movement of Qi, a life force that flows between energy meridians in our bodies. In contrast, Western medicine anchors itself in observable patterns and objective, measurable data points. Both systems promote health and healing, but from within vastly different systems of knowledge. Some alternative practitioners have tried to bridge the gap, drawing selectively on the science of Western medicine while maintaining the basic principle of esoteric “energy fields,” but it’s often an awkward fit.
After my acupuncture session, I left the clinic feeling noticeably better than I had before I arrived. I felt loose. My head was clear. My shoulder wasn’t sore. Was it placebo? How could I explain it? I’ve been trained to doubt even the most rigorous medical trials. In medical school and residency we learn to pick apart studies, combing through their methods looking for statistical biases and any reason to mistrust the data. I felt better after acupuncture, sure, but I still couldn’t bring myself to say “it worked,” given the dearth of hard evidence.
That might not matter. Americans are increasingly willing to try this treatment, according to data from the National Institute of Health. Their data also show that acupuncture accounts for a portion of the $14.6 billion of uninsured, out-of-pocket funds spent annually on “complementary” health practices in America. It’s not a cheap endeavour. My own session cost $98 CAD ($76), equivalent to the price of about eight bottles of Tylenol, a lifetime supply for most people.
When patients used to ask me if there were any supplements, vitamins, oils, or other alternative therapies that they should be using to manage their pain, the message was simple: “Not really,” I told them, “Unfortunately there isn’t any good evidence for that stuff.” In my examination room, like thousands of others across the Western world, the “pain ladder” reigned supreme. But in the midst of an opioid epidemic that’s killing by the thousands, and bearing in mind that there’s some evidence for acupuncture, when does our compassion and our oath as physicians to “do no harm” trump the status quo?
In December, the American Pain Society endorsed the use of acupuncture for chronic pain, suggesting that this ancient technique could be part of a new, holistic approach within the context of Western medicine. When a frustrated patient, walking the dark path toward opioid addiction, asks me if they should try acupuncture, at least now I can tell them it’s worth a shot.