Ep. 20: Is acupuncture just a placebo? And what even is the placebo effect?

00:00 SPEAKER_00 Hello, dear listener, Alexa here. You are about to listen to the 20th episode of the Notes from Your Acupuncturist podcast. I'm so excited to hit this milestone. And if you're excited too, I've got a big favor to ask. If you enjoy this show, I'd love for you to help me celebrate by leaving a rating or a review on your podcast listening app. It only takes a minute and it really helps other people discover the show. Thanks for helping me get to 20 episodes. Let's keep going. 

Welcome to Notes from Your Acupuncturist, the podcast for anyone who's interested in acupuncture, complementary medicine, holistic health, and self-care. I'm your host, Alexa Bradley-Hulsey. If you enjoy this show, you can help other people discover it by leaving a rating or a review, by following or subscribing on your favorite podcast listening app, or simply by telling someone about it. And if you'd like to support this show financially, you can become a paid subscriber on Substack for just a few dollars a month. Just head over to Substack.com and search Notes from Your Acupuncturist or click the link in the show notes. And one more thing before we get started, just a disclaimer that this podcast is for educational purposes only and is not a replacement for medical care from a qualified healthcare provider. Okay, on with the show. 

Hello, everyone. Thank you for being here. Welcome to Notes from Your Acupuncturist. I'm your host, Alexa, and today is a solo episode where I answer your questions or talk about acupuncture in the news or just ramble on about whatever topic interests me. If you have a question about acupuncture, I would love to hear from you. You can get in touch with me on Substack, on Facebook or Instagram or on my website, and all of those links are in the show notes. So today on the podcast, I'm going to answer a question that I've been asked many times, as have most acupuncturists, which is, isn't acupuncture just a placebo? And to that I say, good question. And no, it's not. So let's get into why acupuncture is not just a placebo. 

So first of all, what even is a placebo? A placebo is defined as anything that intentionally has no therapeutic value. Placebos are crucial to the development of new medical treatments because a placebo gives researchers a way to compare results. So let's say you're a scientist and you've been developing a new drug to treat a medical condition, we'll say eye twitching. You get a bunch of research study participants to help you test this new drug, and you give half of the participants the pill you've developed and the other half you give a placebo. And this usually takes the form of a sugar pill. So everyone's taking a pill and no one knows if they're taking the quote unquote real pill or the sugar pill. And in a double-blind study, you as the researcher don't even know who's in which group. The group that gets the sugar pill is known as the control group. As the researcher, what you hope will happen is that you'll see more improvement among participants in the group that gets the real pill. This is called the intervention group. If overall, people in the intervention group report less eye twitching than people in the control group, your clinical trial is a success. Congratulations. But you might notice something. Some of the participants who took the fake pill will also report less eye twitching. Their symptoms will improve even though they only took a sugar pill. This is thanks to the power of the placebo effect. 

The word placebo means I believe in Latin. And the essence of the placebo effect is that belief in a treatment may sometimes be enough to change the course of illness. Placebos are powerful and the placebo effect is very real. In most clinical trials, some percentage of participants in the control group who receive the placebo will still report an improvement in symptoms despite the fact that they didn't actually receive the intended therapeutic intervention. And this will sometimes happen in acupuncture studies. One group will receive the real acupuncture treatment while another will undergo what's called sham acupuncture. And what differentiates real acupuncture versus sham acupuncture will vary. So let's go back to our example of eye twitching and say you're a researcher looking into whether or not acupuncture helps with eye twitching. The participants in your real acupuncture group or your intervention group might get needled at the point liver three on the foot. And this is because the location of liver three is pretty widely agreed upon by most acupuncturists. And most acupuncturists will agree that it's useful for eye problems. And now your sham acupuncture group is going to be used for comparison. And the participants in this group might have needles placed just in random spots on the body points that maybe don't fall along a meridian pathway or points that just aren't widely accepted acupuncture points. So therefore it's assumed that they have no therapeutic value. Or you might use some sort of device that would simulate the experience of getting acupuncture but isn't actually acupuncture, like a retractable device that would press the skin but not actually insert a needle. Sham acupuncture is pretty tricky to design. It's way more complicated than giving someone a sugar pill. So you have to get a little creative with how you administer it. So you'll compare the results of your real acupuncture group against your sham group. And what you'll likely find is that the sham group has some improvement in their eye twitching, but not as much as the real acupuncture group. But you might learn that the sham acupuncture group has just as much improvement as the real group. 

This has actually happened in numerous acupuncture studies. And this outcome of the placebo group showing just as much improvement as the intervention group will even happen in studies involving pharmaceutical or surgical interventions. There was a 2013 study in Finland that looked at the efficacy of a very common surgical procedure of the knee, an arthroscopic partial meniscectomy to treat symptoms of a partial meniscus tear. Okay, so they divided participants into two groups and half underwent the standard surgery and then half of the participants had sham surgery. And the sham surgery was basically a simulation of the real thing without any actual cutting or removing anything. So they didn't really have surgery, they just thought they had surgery. And then both groups had the same post-operative care. And guess what? The results of the two groups were identical. That's right. The people who only thought that they had surgery had just as much improvement as the people who actually had surgery. That's how powerful the placebo effect can be. 

And further studies have shown that the placebo effect can work even when you know you're taking a placebo. A 2010 study looked at the treatment of irritable bowel syndrome using open label placebos. So in this study, 80 participants were given a placebo to treat their IBS. They were instructed to take two sugar pills a day. The doctor told them that they were getting a placebo and the bottle even had the word placebo printed on it. So these participants knew full well that they were taking pills that had absolutely no therapeutic value and they felt better anyway. 60% of the placebo group reported an improvement in symptoms versus 35% from the group who received no treatment at all. Placebos work. 

Now there are a lot of theories as to how and why placebos work. And there are a few in particular that I think are relevant to our question of whether or not acupuncture is a placebo. So I will discuss those briefly. One theory is that a placebo may cause a change in behavior. When a person is taking a pill to treat a medical condition, they might be more motivated to make lifestyle changes like eating more healthy foods that could positively impact their health. And I certainly see this with my acupuncture patients. They're doing acupuncture to address a health concern, but maybe they've also changed how they eat or they've started seeing a therapist or they're doing yoga or Qigong. In the real world, it can be difficult to parse out which intervention is having what impact on the body. And often all of these changes have a synergistic effect. That doesn't mean that the acupuncture isn't actually doing anything therapeutic. It just means that it's one part of a bigger picture. 

Another theory is that taking a placebo and expecting to feel better may reduce anxiety, which may in turn trigger the release of endorphins, which are the body's natural pain relievers, and may reduce the levels of stress hormones in the body, such as cortisol. And as I discussed in episode 12, acupuncture has been shown to have these types of beneficial effects on the nervous and endocrine systems. So again, it's not that the acupuncture isn't doing anything therapeutic. It's more that the acupuncture is prompting the body to self-modulate into a healthier and more balanced state. 

And there's another theory called remembered wellness. And this is when the subconscious mind remembers a past state of wellness and replicates it in the present. A placebo may help the brain remember and visualize a time before the onset of illness and then bring about changes in the body to recreate that state of health. And if this sounds a little woo woo to you, remember that their brain also has the power to bring about a state of illness. This is what happens in white coat syndrome, when a person who has normal blood pressure will suddenly experience high blood pressure when they're at the doctor's office. The brain associates the doctor's office with illness and anxiety and produces physical symptoms of disease. So it can work in the opposite way too. The brain may associate a placebo with health and make physical changes accordingly. The brain is powerful. I experience this myself when I get acupuncture. I settle into my chair, get comfortable, and become extremely relaxed before the first needle even goes in. That's remembered wellness. So those are some theories as to how and why a treatment that has no intended therapeutic value can nevertheless bring about a therapeutic result. And these theories really just show us that healing is complicated. It's multifaceted and multilayered. And a lot of how healing happens just can't be quantified. It's really hard to break healing down into component parts. 

So we'll get back to the question of whether acupuncture is a placebo in just a minute. But first, a quick break and a word from this episode's sponsor. Are you an acupuncturist looking for an integrated appointment scheduling, electronic health records, and payment processing software system? Check out this episode's sponsor, Open Acu, a system created for acupuncturists by acupuncturists. Open Acu helps manage your practice so you can focus on what you do best, taking care of your patients. Podcast listeners can save $75 when you use the coupon code podcast at checkout. See all the details at openacu.net. That's openacu.net promo code podcast. 

Okay, so we've talked about what a placebo is and why it works. So now let's tackle the question of whether or not acupuncture is a placebo. Because when people say, oh, isn't acupuncture just a placebo, it's usually said in a rather dismissive way. There's an implication that acupuncture doesn't actually do anything and that any positive benefits are solely the result of the power of suggestion. So I'm going to talk about why that isn't really the case. 

First, I have two very well-documented examples of where the placebo effect doesn't apply. One of those I mentioned back in episode 17 with Jerusha deGroat-Stevens when we talked about how acupuncture supports a healthy pregnancy. Every acupuncturist I know has observed the particular phenomenon of increased fetal activity during an acupuncture treatment. I hear this from my pregnant patients all the time. The needle goes in and the baby starts moving. And to an acupuncturist, this makes perfect sense. We're stimulating the flow of chi with the needles, which in turn increases circulation, and a fetus is going to feel and respond to all of that increased movement in the mother's body. But the baby doesn't know that mama is getting acupuncture. It's not a placebo to the baby. 

The second instance of where the placebo effect doesn't apply is in veterinary acupuncture. Acupuncture is widely used in veterinary medicine for a huge range of conditions affecting animals. It's used on pets, on farm animals, and by zoos and animal rehabilitation organizations. I've used acupuncture on my own dogs, and I've seen stories of acupuncture being used to treat cats, chickens, birds of prey, horses, elephants. They have to use really long needles for those. Porcupines, which is hilarious if you think about it. Exotic animals whose names I can't even pronounce. Probably a bunch of other animals I'm forgetting, and even snakes and crocodiles. Now, as far as I know, animals don't have a belief system. So how could they be affected by a placebo? They have no preconceived notions about whether or not a medical intervention will help them. All those theories I mentioned as to how and why the placebo effect works, they don't apply to animals and gestating babies getting acupuncture. 

Okay, so let's talk about another reason why the power of suggestion isn't the only explanation for why acupuncture works. It turns out that sham acupuncture, which I mentioned earlier, does have an effect on the body, but it does something different than quote unquote real acupuncture. And the evidence for this comes from a series of recent studies. A 2017 study at Harvard Medical School looked at electroacupuncture for the treatment of carpal tunnel syndrome. And this is a very commonly treated condition with acupuncture. So participants in both the real acupuncture and sham acupuncture groups reported immediate improvement right away after a treatment. But only the true acupuncture group had reduced pain after three months. And this suggests that improvements in the sham group were perhaps due to the placebo effect, but that the true acupuncture had an effect on the underlying cause of pain. And the assessments used in this study backed this up. The true acupuncture group showed measurable improvements in the speed of nerve transmission and in the somatosensory cortex of the brain. And these improvements were not seen in the sham group. 

And a 2009 study at the University of Michigan used brain scans to investigate whether acupuncture releases endorphins in the same way that placebos do. So they gave fibromyalgia patients either real acupuncture or sham acupuncture, then followed up with a PET scan of the brain. Both groups reported a reduction in pain, but the brain scans showed very different mechanisms at work. The placebo group showed fewer free opioid receptors in areas of the brain associated with pain regulation. And this suggests that sham acupuncture caused a flood of endorphins, which are the body's natural pain relievers. So researchers expected to see similar findings with the real acupuncture group, but instead they saw the opposite. After a real acupuncture treatment, the number of free opioid receptors actually surged. And this would suggest either fewer endorphins released in response to acupuncture or an increase in the overall number of receptors. But yet these patients still reported pain relief. So whatever the real acupuncture was doing, it wasn't working as a placebo. This is interesting in the case of fibromyalgia, because fibromyalgia patients have fewer opioid receptors than the general population. And this leaves them less responsive to endorphins and overly sensitive to pain. And the study suggests that real acupuncture brings their opioid receptor levels back up to normal levels. So the pain relief they experience in response to real acupuncture is actually the result of correcting the underlying cause of pain. In Chinese medicine, we call this treating the root and branch. Acupuncture relieves the symptoms and also the underlying imbalance that causes the symptoms. In essence, these two studies show that while the relief experienced from sham acupuncture may be the result of the placebo effect, the real acupuncture works in an entirely different way by treating both the root cause and the branch symptoms. 

And one final note on whether or not acupuncture is a placebo. Remember that by definition, a placebo is anything that intentionally has no therapeutic value. When a researcher gives a participant a sugar pill, it's with the intention and expectation that that sugar pill will have no therapeutic impact. A placebo is by design meant to do nothing. But acupuncture is very much the opposite. It's delivered with purpose and intention. As acupuncturists, we don't try to force an agenda, but we do approach a treatment with the objective of helping the patient in some way using the tools that we have. Unlike a placebo, acupuncture is meant to do something. So therefore, it doesn't meet the definition of a placebo. Now before we wrap up, I think it's important to circle back to the benefits of the placebo effect. Placebos help people in very real, well-documented ways. Study after study shows that a percentage of patients receiving a placebo do get better, even when it comes to something like sham knee surgery, or even when they know they're getting a placebo. It's wild. Placebos benefit us in ways we can't quite quantify, but are nonetheless very real. 

And I want to close with a quote from author Seth Godin. Here's what he says about placebos. Quote, the placebo is a prompt for our subconscious to do the hard work of healing our body, increasing our satisfaction, or maximizing our performance. When someone says that's just a placebo, they're undervaluing the magic of culture and the power of our minds to actually influence how our bodies perform, unquote. I couldn't have said it better myself. 

Well, that's it for today's episode number 20. Yay. Don't forget to leave a rating or review if you enjoy this show. Be well out there, friends. Thanks for listening. 

Thank you for listening to today's episode of Notes from Your Acupuncturist. If you liked what you heard, please follow this show, leave a rating or review, or just tell someone about it. And if you want to join the conversation, you can subscribe to Notes from Your Acupuncturist on Substack, where you can comment, ask questions, participate in discussion threads, watch videos, and read more of my reflections on acupuncture and healing. Huge thanks, as always, to our paid subscribers for helping keep this work sustainable. You, too, can become a paid subscriber for just a few dollars a month. Just head over to Substack.com and search Notes from Your Acupuncturist or click the link in the show notes. Until next time, this is Alexa Bradley-Hulsey, your acupuncturist, signing off with love and gratitude.