Placebo Is Not Your Enemy, Redux

more about what acupuncture points do (and don't do)

Art by A. Cohen

We have a bunch of new subscribers this week — hi, welcome! And thank you to Diet Poke for the shout-out. If you like this newsletter, I bet you’d like Diet Poke (especially this post, which has a closing paragraph so good that I read it at least ten times).

There are endless ways to practice acupuncture, and to receive acupuncture, and none of them are wrong. WCA and POCA Tech are devoted to acupuncture as a people’s medicine, as medicine for the people — in which case it’s good to understand how acupuncture works IN people, as opposed to in textbooks.

Last year I wrote a post titled Placebo Is Not Your Enemy: It’s Your Weird Friend. I thought it might be worth revisiting as a follow up to the last couple of posts about what acupuncture points do (Part One and Part Two). I want to make an inventory of factors that contribute to the effectiveness of any individual acupuncture treatment.

Acupunks often wonder (and patients do too): why did that one particular treatment work so well, as opposed to the ones before it and after it? As a practitioner this question can be especially frustrating if you spend a lot of time researching your treatment strategies outside of clinic only to discover that your patient’s results may not be proportional to your efforts. True story: I once worked with an acupuncturist who quit the field over this. (There were multiple factors, but this was the last straw.)

WCA Cully is big enough that pre-pandemic, we usually had two acupuncturists working at the same time. One morning, before our shift started, my coworker — a smart guy — was reviewing the patients on his schedule when he noticed a returning patient whom he’d treated only once, a couple of years ago, back when he was a brand new practitioner. He looked at the chart notes to see what he’d done and exclaimed, “What a lousy treatment! I can’t believe I did that, what was I thinking? No wonder she hasn’t been back in. Oh well, at least I’ve learned something since, I’ll do better today.” On that same shift, he was scheduled to treat a patient he’d been seeing weekly, who was struggling with a stubborn chronic condition. He’d spent many hours poring over acupuncture books and meticulously crafting his treatments to come up with something he felt really good about. He was looking forward to hearing about his patient’s progress.

You can guess what happened next.

When I saw him again at the end of the shift, he looked deflated. “What’s wrong?” I asked. He told me that his first patient, the one who’d gotten the lousy treatment, was delighted to see him. She explained that she hadn’t been back to the clinic in years because she hadn’t needed to. The treatment he gave her was life-changing, she said. It resolved her excruciating back pain. She had returned only because she had a completely unrelated problem (she’d sprained her wrist or something). Meanwhile, the second patient, the one for whom he was doing his absolute best work, reported no improvement at all.

I could tell he felt personally insulted. The juxtaposition was just too much, like the acupuncture gods were laughing at him. A month or so later, he quit and got a job in tech.

So, yeah, this is why you have to get your ego out of your practice, because the acupuncture gods WILL laugh at you. All the time. Life is absurd and so is acupuncture — you can’t take it personally. The acupuncturist who quit graduated from the same fancy acupuncture school that I did, where they put a premium on practitioners’ intellectual grasp of acupuncture theory and ignored almost everything else. I think about him sometimes when I’m teaching POCA Tech students. I don’t want to set them up for similar disappointments.

So here’s my inventory of factors that contribute to the effectiveness of an acupuncture treatment — only one of them is specific to the particular acupuncture points the practitioner chooses, and only two of them are things the practitioner actually has any control over. No matter how smart they are.

In descending order of importance:

1. the global impact of acupuncture: no matter what points you do, acupuncture will reliably regulate the nervous system, reduce inflammation, and buffer the effects of stress on the body. It’s a shotgun, not a laser; there’s only so much you can do to aim it.

2. the patient’s contribution, aka quantum effects: no matter what points you do, the interaction between acupuncture and your patient’s body is not predictable. Acupuncture works much better for some people than others. And every treatment, even when it’s the same points needled on the same person by the same acupuncturist, is a unique encounter.

3. placebo (more about this in a minute)

4. which acupuncture treatment strategy you use: acupuncture points only have meaning within the larger context of a particular treatment strategy. The same acupuncture point can mean different things in a Balance Method treatment vs. a Korean Four Point treatment vs. a Traditional Chinese Medicine treatment. Just like acupuncture in general works better for some people than others, certain treatment strategies seem to work better for some patients, and some practitioners, than others. It’s a matter of trial and error which is why, at POCA Tech, we teach students multiple approaches; we want them to get used to trying things in order to find out what works best for them and their patients. But I put this factor last for a reason: the other three collectively outweigh it. By a lot.

Okay, let’s talk about placebo.

Art by A. Cohen

In the rest of the acupuncture profession, practitioners generally treat the idea of placebo as an obstacle to acupuncture’s legitimacy. “Acupuncture is not a placebo!” they say. Maybe it isn’t, but I think that argument’s counterproductive. Placebo reflects the power of relationship. Any time you’re making an effort to align your patient’s intention for healing with your own intentions for the treatment, you’re summoning placebo. You might say it’s a form of empowerment, and as such it’s a tool that acupuncturists can and should learn to use skillfully.

The research on placebo is fascinating. Check out this opinion piece by Ted Kaptchuk in the New York Times and this story in Wired Magazine about “open label” placebos (meaning placebos that work even when people know they’re placebos). Here’s a quote from the first article:

Placebo effects are health improvements initiated from the rituals, symbols and behaviors involved with healing. A 2020 review I co-wrote in the medical journal The BMJ examined data from over 140,000 patients with various chronic pain conditions. We found that placebo responses range from moderate to large and can account for 50 to 75 percent of the benefits of drug treatments for pain.

In the context of the opioid epidemic, that last sentence is pretty heartbreaking — also a compelling argument for more research on placebo.

Thoughtfully using placebo is an aspect of your treatments that you can actually work on, as opposed to the factors you have no control over. If somebody told you that there was a treatment strategy for acupuncture that allowed you to access up to 75% of the benefits of pain medication, wouldn’t you want to try it? Other research indicates that morphine (morphine!) is twice as effective when given by a nurse compared to being administered by a pump.

Most of what I know about placebo, I learned from my patients. When I unpin someone, I always ask, “how was your treatment?” One day a patient said to me, “I don’t feel any different right now, but I’ve gotten a lot of acupuncture over the years and I know that usually, I don’t feel any changes until the next day — it’s like something kicks in overnight.” I thought about it and realized that I’ve had the same experience. Generally I feel better immediately after a treatment, but sometimes the effects are delayed, or they’re even stronger the next day. So I started saying to all my patients, especially new ones, “Sometimes acupuncture kicks in overnight. So please notice how you feel when you wake up tomorrow, and tell me the next time you come in.” That’s a way of seeding positive expectation — and also cueing patients to notice subtle changes they might otherwise overlook.¹ It’s also a way of unapologetically wielding placebo.

(I’m unapologetic because I spent 20-some years treating chronic conditions in high volume settings, often with marginalized people who had complex bio-psycho-social stressors. Not much was on my side, or my patients’ side. Placebo was, and is, and I’m grateful.)

There are of course acupuncturists who will disagree vehemently with my inventory (some of them are probably hate-reading this newsletter — hi!), who will swear up and down that the most important determinant of a treatment’s success is the brilliance and skill of the acupuncturist, that acupuncture has nothing to do with placebo, it really is a laser and you really can aim it, and I’m just a low-class hack who’s devaluing the profession. That’s fine, I’m used to it. If you believe acupuncture is like a lightsaber and you’re a Jedi Master, you can probably convince your patients of that too. Your confidence will boost the placebo effect for them. Go for it! I don’t have any problem with that.

The only part I object to are the political implications. To reiterate: what you believe that acupuncture points can do inevitably connects to how you think acupuncture should be taught and regulated. Which leads directly to problems like ridiculous debt-to-income ratios for acupuncturists, and indirectly to acupocalypses.² The thing is, there’s no evidence that acupuncture can be aimed like a laser, there’s no evidence that any acupuncture treatment strategy works better than any other, and indeed it would be hard to prove that acupuncture points themselves… exist?³

I think what the Jedi Masters are concerned about is acupuncture’s legitimacy in the eyes of the Medical Industrial Complex. And what’s most interesting about placebo is that it points toward a different kind of legitimacy.

The people who taught me that acupuncture was real — and valuable — were my patients. They taught me to expect that acupuncture would work and that I could reliably get good results. The legitimacy I most wanted was for my community to use acupuncture and benefit from it, and that’s the legitimacy I got. Placebo doesn’t have to make you wonder whether acupuncture is real; placebo is a reminder of how things can become real, and useful, as a result of people using them.

1. For more about how to help patients track subtle changes and why that’s important, especially for pain management, see Punking: the Praxis of Community Acupuncture.

2. Another long-established, top-ranked acupuncture school just announced that it’s closing, with only six weeks notice to students: Emperor’s College in Los Angeles. This is now indisputably a trend. To recap the recent casualties: SWAC 8/23, ACTCM 2/24, AOMA 5/24, OCOM 9/24, and AMC 9/24 (with no advance notice at all). That’s six prominent schools shuttered in less than two years. Meanwhile MUIH has ceased enrollment and is in the process of a teach-out; Bastyr and East West College are in trouble with their accreditors. Other schools have sold their buildings and are downsizing: AFEA in Florida and NUNM in Oregon, while Bastyr has a campus up for sale. I’m working on an updated Cockroaches of Acupuncture post — lots has happened in a year.

3. There IS evidence that frequency of treatment contributes to efficacy (see: the Gerac Trials). At WCA, we say that frequency beats cleverness. It’s why community acupuncture has so many systems designed to make treatments less expensive and more accessible — to give as many people as possible a shot at frequent, regular acupuncture and maximize their odds of relief. Also, why we focus on speed.