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Special Report

Getting the Point?

As the US is hit hard by the opioid crisis, doctors and patients are turning to acupuncture. Can the method become a powerful weapon to turn the situation around or is it just a placebo?

By NewsChina Updated Feb.1

Lying on an examination bed in a dim room, with 13 needles sticking in her lower back, knees and thighs, Miné Ayberk, for about 25 minutes, finds herself in a tranquil state of mind. The pain she feels has largely gone.  

Twelve years ago, Ayberk suffered from severe stomachache and tried every method she could think of to help relieve her suffering, including dietary changes and medications, all to no avail. Worried about side effects from the drugs, she asked her doctor for alternatives. That was how she ended up trying something she had always wondered about: acupuncture. 

After a couple of 25-minute sessions, all paid for out-of-pocket, she found her pain had greatly eased. That was the moment she fell in love with this ancient Chinese healing practice. Over the next decade, she turned to acupuncture whenever she wanted to ease the pain caused by chronic ailments like arthritis, or simply to boost her energy. 

“Acupuncture works for me,” said Ayberk, a sommelier living in Manhattan. “It’s relaxing and it’s safer.” 

Ayberk is one of millions of people in the US who have tried acupuncture, mostly for chronic pain, according to a National Health Interview Survey (NHIS) released in 2008, which stated that 6.3 percent of the US population, or around 14 million people, had tried it.  

In October 2018, US President Donald Trump signed a bill called H.R.6, which aims to battle the ongoing opioid crisis in the US and find alternative therapies to treat chronic pain. The bill included  
stipulating that acupuncture, among other alternative therapies, such as medical massage, was to be evaluated.  

This means that acupuncture could be recognized by the US Department of Health as one of the pain replacement therapies covered by Medicare, a federal health insurance program that covers people aged 65 and older, or who have a severe disability. 

Opioid Crisis
The US has been in the grip of a deadly opioid epidemic. During 2017, more than 49,000 died in the US from overdose that involved an opioid – a record high, which was triggered by an explosion in prescriptions of powerful painkiller pills initially, but when that supply was cracked down on, people turned to illegal drugs such as heroin, and increasingly synthetic painkillers such as fentanyl. A report from Altarum, a healthcare research organization, published in November 2017 showed the cost of the opioid epidemic to be US$95 billion for 2016. A 2017 US government report, which included an assessment of the intangible value of life, put the cost of the epidemic at US$504 billion, Altarum said in an update. On October 26, 2017, the Trump Administration declared the opioid crisis a national public health emergency, and called for solutions. 

Fighting side by side with medical professionals, public health officials are working hard to find new ways to reduce the use of opioids. In addition to limiting prescriptions of painkillers, the public health system has also been expanding medical insurance coverage to alternative treatments, including acupuncture.  

“The opioid epidemic in America has been an overshadowing situation here, and also, at its root, has been a primary driver in the search for non-pharmacologic solutions to pain,” said David Miller, Chair of the American Society of Acupuncturists. Among other alternatives to painkillers, “acupuncture stands out as the most evidence-based, safest, and most easily integrated option to help the public,” he told NewsChina in an email interview.  

Currently, a number of commercial medical insurance companies cover acupuncture and a handful of states hit hard by opioid overdoses, including Ohio, Massachusetts and New Jersey, cover acupuncture through Medicaid, a medical program that is funded jointly by states and the federal government targeting low-income patients. 

The largest federal government insurance program, Medicare, does not pay for acupuncture.  

The federal agency that determines whether or not to cover a medical treatment by Medicare is the Center for Medicare & Medicaid Service (CMS). When making national coverage determinations under section 1862(a)(1) of the Social Security Act, the CMS evaluates relevant clinical evidence to make a decision.  

Based on research by three units of the National Institutes of Health, the National Institute of General Medical Sciences, the National Institute of Neurological Diseases and Stroke and the  
Fogarty International Center, the CMS made non-coverage determinations for acupuncture, in 1980 and 2003 because “CMS found the evidence did not support Medicare coverage,” a  
spokesperson from the CMS wrote in an email to NewsChina. 

“Once an analysis is opened, the process takes approximately nine to 12 months,” added the spokesperson, “at this time, CMS hasn’t announced plans to initiate another national coverage analysis of acupuncture.” 

Decisions made by the CMS did not dampen the enthusiasm of supporters of the treatment, who view the signing of H.R.6 as an opportunity for Medicare to cover acupuncture in the future.  

“Coverage would provide widespread familiarity with and access to acupuncture and licensed acupuncturists,” Miller said, who is optimistic that acupuncture will be ultimately covered by Medicare in the next few years. 

Waste of Resources
While backers say alternative pain therapies like acupuncture are a crucial part of the strategy to limit opioid prescriptions and curb abuse, skeptics argue it is just a waste of money and resources. 

David Gorski, a surgical oncologist at the Barbara Ann Karmanos Cancer Institute in Detroit, specializing in breast cancer surgery, is among the staunch opponents who think that acupuncture should never be covered by Medicare because “money going to cover  
unproven treatment is money that is not going to cover science-based medicine,” he said in an email to NewsChina. “At the very least, covering unproven treatments like acupuncture increases costs without benefiting patients.”  

The controversy over the efficacy and effectiveness of acupuncture has accompanied the development of the treatment in the US. 

There is a general consensus that some form of acupuncture as a treatment may have existed in China for around 2,000 years, but it remained largely unknown to Americans until the early 1970s. In 1971, The New York Times columnist James Reston wrote an article about his experience with acupuncture in Beijing. Thefollowing year, former President Richard Nixon visited China. On his return, Major General Walter R. Tkach, of the United States Air Force and physician to Nixon, published his personal experience of acupuncture in the July 1972 issue of Readers Digest, titled “I Watched Acupuncture Work.” Both articles helped raise public awareness about acupuncture in the country.  

In 1971, Dr. Samuel Rosen, a New York ear surgeon, one of the first American physicians to be invited to visit the People’s Republic of China, reported his observation of acupuncture being used as anesthesia during his visit to China, according to an article in The New York Times.  
Since then, teams of US physicians have been to China to witness acupuncture anesthesia being applied in various operations, from open heart surgery to cesarean sections, to tonsillectomies and dental extractions. 

As acupuncture has been increasingly used by doctors and patients over the last four decades, regulations on its practice and safety have developed. Since the National Institutes of Health Consensus Statement in 1997, the landscape of acupuncture regulation has evolved.  

Currently, 47 states and capital Washington DC have already legalized the practice of acupuncture.  

In order to practice acupuncture in those states, one must obtain a license certified by the National Certification Commission for Acupuncture and Oriental Medicine (NCCAOM), which requires that either a practitioner passes the NCCAOM examinations or completes the NCCAOM certification program. 

The number of acupuncture-related educational programs has also risen. Statistics indicate that by 2015, there were 62 master’s degree and 10 doctoral degree programs in the US, which are taught at schools accredited by the Accreditation Commission for Acupuncture and Oriental Medicine (ACAOM), the authority in this field that is recognized by the US Department of Education. A master’s degree in acupuncture is the minimum educational requirement to practice in most states. 

Thanks to increased access to acupuncturists and growing public awareness of acupuncture, as well as expanding data supporting its use, acupuncture has been applied to an increasing number of patients in the US, said Wen Chen, acting branch chief and program director at National Center for Complementary and Integrative Health (NCCIH).  

Yet, while this centuries-old Chinese healing method is gradually making its way into mainstream consciousness in the US, critics are skeptical of its scientific merits.  

University of Miami Acupuncture Physician Garrett Krause places acupuncture needles into Cristi Bundukamara during the Integrative Medicine symposium at the University Of Miami Miller School Of Medicine in Miami, Florida, April 23, 2010

Doctor Tian Xiaoming treats an arthritis sufferer at acupuncture center in Maryland

Balancing Energy
Acupuncture customarily involves inserting thin metal needles into specific points on the human body. As practiced today, it is often combined with other interventions, such as sending a small current of electricity through the needles or burning herbs on the acupuncture points (a practice called moxibustion). According to traditional Chinese medicine (TCM) theory, there are as many as 2,000 acupuncture points on the human body that are connected by 12 main meridians, which conduct energy, called qi through the body. By sticking needles in the right spots, acupuncture can balance yin and yang and allow the flow of qi throughout the body, which ultimately spurs natural healing and pain relief.  

However, despite countless studies into acupuncture since the 1970s, little evidence showed that any force resembling qi exists, and how exactly qi can work on the human body to cure pain remains unclear. 

“Just because the Western medical system can’t explain how acupuncture works, it does not mean it really doesn’t work,” Chen Decheng, a licensed acupuncturist in New York City and the director of the TCM and Acupuncture Inheritance base of New York, told NewsChina.  

Chen is not the only one to defend the therapy.  

Some acupuncturists argue that needles trigger the release of endorphins – pain-numbing chemicals. Others have claimed that it works through the “gate control theory of pain,” proposed in the 1960s by Patrick Wall and Ronald Melzack. The theory claims that acupuncture may activate peripheral nerves to shut the “gate” on pain signals traveling through the central nerve system. Therefore, stimulation by acupuncture is able to suppress pain.  

But for critics, the most plausible explanation for why acupuncture helps some patients is the placebo effect. 

In the June 2013 issue of medical journal Anesthesia and Analgesia, pharmacologist David Colquhoun and neurologist Steven Novella challenged: “The benefits of acupuncture are likely nonexistent, or at best are too small and too transient to be of any clinical significance,” they wrote. “It seems that acupuncture is little or no more than a theatrical placebo.”

There have been many clinical trials on the effectiveness of acupuncture, but the results are contradictory due to the difficulties administering the tests. The gold-standard for a medical trial is a double-blind experiment, a randomized controlled trial, in which neither the participants nor the experimenters know who is receiving a particular treatment. This procedure is used to prevent bias in research results.  

However, it is difficult to conduct such tests on acupuncture because patients will notice immediately when the needles are stuck in them and acupuncturists know whether they are doing real acupuncture or not. Even though some trials have used an improved device which simulates the effect of a needle pricking the skin, it is not truly double blind as the doctor is aware which treatment is real.  

In order to conduct unbiased studies and to do so more effectively, in the past few years, researchers have been using meta-analysis, a statistical procedure for combining data from good trials, on acupuncture, mostly in pain. 

In the May 2018 issue of the Journal of Pain, a meta-analysis published by a group of researchers led by Andrew Vickers of the Memorial Sloan-Kettering Cancer Center, New York, looked at data received for a total of 20,827 patients from 39 trials. The results showed that in certain pain conditions “acupuncture was superior to sham as well as no acupuncture control,” and the team also found “clear evidence that the effects of acupuncture persist over time with only a small decrease, approximately 15 percent, in treatment effect at one year.”  

But critics, like David Gorski, who is also managing editor of a medical information website called Science-Based Medicine, are not convinced. He pointed out that the flaws of Vicker’s study are obvious: the study was not double-blind and the paper has publication bias. He added that the study shows the effect of acupuncture might be statistically significantly greater than placebo effects but it also “shows that acupuncture doesn’t have clinically significant effects.” 

Some supporters argue that even if acupuncture has placebo effect, it is worth trying. “Patients do not care about its medical mechanism,” said Chen Decheng, who has been practicing acupuncture in New York since 2004 and witnessed the increase in the number of patients  
using acupuncture in the country. “As long as it can ease pain, it doesn’t matter that the mechanism can’t be explained by modern science,” he added.  

Or it does.  

“Acupuncture is not without risks. To be sure, its risks are low, but its benefits are zero,” said Gorski, “consequently the risks outweigh the benefits.” 

It is most likely that the debate over the efficacy of this ancient healing method will continue. As Wen Chen of the NCCIH, an organization which has researched alternative medicine, including acupuncture for over 30 years, said, “the effects of acupuncture on the brain and body and how best to measure them are only beginning to be understood.” 

But for many patients like Miné Ayberk, whose father is a doctor, there is something certainly that speaks louder than scientific data: “Without it, I am not able to feel this good.”