Ep. 24: Is acupuncture safe? Exploring the risks and side effects

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, and I'm going to talk about a pretty frequently asked question about acupuncture, which is, is it safe? A lot of my solo episodes are based on questions from listeners, so 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 let's get on to today's topic, the risks, side effects, and safety record of acupuncture. So I was inspired to address this topic after a recent news story I saw about a woman who suffered a double pneumothorax after an acupuncture treatment, which required emergency surgery and it could have been fatal if left untreated. And I'll put a link to the article in the show notes for anyone who's interested in reading. And that article just made me think that it's important to talk about the risks of acupuncture because, like all forms of medicine, it is not entirely risk-free. It is very safe. But there are some potential side effects, and I want to give some context so that we can have a fuller picture of what it actually means when we say that acupuncture is very safe. 

So I want to start by talking about this pneumothorax story because this really is the worst of the worst when it comes to potential side effects from acupuncture. So first of all, what is a pneumothorax? This is just a fancy way of saying a collapsed lung, and this will occur when air gets into the space between your lung and the chest wall, and the air outside of your lung pushes onto the lung and causes it to collapse. This is usually caused by a chest injury, like a puncture wound or blunt force trauma to the chest, but it can also be caused by underlying lung damage. In some cases, a pneumothorax will happen for no discernible reason at all, in which case it's called a spontaneous pneumothorax. A pneumothorax can affect the entire lung or just part of the lung, and the most common symptoms are sudden chest pain and shortness of breath. It's treated by inserting a needle into the chest wall to remove the excess air, and it's usually considered a medical emergency, although sometimes a small pneumothorax will heal on its own. Obviously, if you're ever experiencing sudden chest pain and shortness of breath, you need to seek immediate medical assistance. A severe pneumothorax that isn't treated can be life-threatening, but in most cases, people recover just fine with the proper treatment. 

So let's go back to this recent news story of a woman who suffered a double pneumothorax after acupuncture, which means that it occurred in both lungs. This happened in New York, and according to the news article, this particular acupuncturist who treated her was unlicensed. The woman had received several treatments from this practitioner over the prior 18 months, but after her most recent treatment, she developed shortness of breath and collapsed. A bystander actually saw her and called 911, and doctors determined that both of her lungs had collapsed as a result of acupuncture. She had to have emergency surgery, and she likely would have died if doctors hadn't intervened. She ended up being hospitalized for six days, and now the practitioner who treated her is facing several criminal charges, including assault, reckless endangerment, and unlicensed practice of a profession. 

So one thing to note about this story is that the practitioner who caused the pneumothorax was unlicensed. I don't know any of the circumstances surrounding his practice, where he was educated, how long he'd been doing acupuncture, or anything about his background, including why he was practicing without a license. So I'll just say this. There's a reason why most states regulate the practice of acupuncture, and it's generally starting from a place of trying to protect the public. And I say this as someone who has served on my own state's acupuncture board for many years. Regulation of any medical practice is done with the best interests of the public in mind. Now, that's not to say that acupuncturists with a license don't ever cause adverse events, because bad reactions and side effects can occur in the hands of even a very experienced practitioner. But when you, as a patient, receive acupuncture from someone who is licensed by a medical board, there is some assurance that the person you're seeing has a baseline level of competency that has been demonstrated in some objective way, usually through educational and exam requirements. And that competency does include training in the safe administration of acupuncture. And I'll talk a bit more about safety training in a minute. So can a pneumothorax occur even if you're seeing a licensed acupuncturist? Yes. Are you more likely to have an adverse event with an unlicensed practitioner? That's hard to say because adverse events with acupuncture are so rare in the first place. But if you're getting acupuncture from someone, you want to have some confidence that they know what they're doing. And so the licensure process is a way to help ensure that the people practicing acupuncture are qualified to do so. So that's all I'm going to say about the fact that the practitioner in this particular case was unlicensed. 

So, you might be wondering, how does a tiny needle the width of two hairs cause a collapsed lung? Well, in certain areas of the body, the chest wall is pretty close to the surface of the skin. So if a needle is inserted too deeply or at the wrong angle, even if it's a tiny needle, there is the risk of it either damaging or puncturing the chest wall, which will then cause air to leak in and then cause the pneumothorax. This will most often happen on the upper back or the top of the shoulder when we insert a needle in one of those areas. Now, I just mentioned safety training and that's very relevant here because in acupuncture school, when we're learning about the points, we don't just learn where they are and what they're used for. we also learn how deeply we can safely needle each point and the angle of insertion we should use. So, for example, points on a part of the leg that typically has a lot of muscle or fat tissue can be needled at a perpendicular angle, so the needle goes straight in, and you can insert it pretty deeply. But points on the upper back are different. We needle those obliquely, so the needle doesn't go straight in. It goes in at more of an angle. And we use a shallow insertion on the upper back. And we also take into account the patient's size and body constitution using a proportional measurement system, which we call sun measurements. So one sun might be equivalent to about one inch on one person, but it might be more like one centimeter on a smaller person. So there are all these different variables to consider, not only when we're choosing which points to use, but also in how we insert the needles. We use very different insertion techniques depending on the part of the body we're needling. And some of that has to do with our therapeutic intent. It's also based largely on safety guidelines. And this is something that's really emphasized in our education and in our credentialing process. 

So a pneumothorax is really the most severe of the possible adverse events with acupuncture. I've been practicing for a long time and I know a lot of acupuncturists and just anecdotally, I've heard stories of a pneumothorax happening with acupuncture, but I've never known a practitioner who's actually caused one. And I think for most acupuncturists, we hear about it, we know it's a risk, but we don't have any firsthand experience with it. So I wanted to find some data about this and see just how often this actually happens. So I found a few studies. One was conducted in Germany and published in 2009. And they looked at all adverse events following acupuncture, not just pneumothorax. They surveyed 229,230 patients, so a pretty large sample size. And altogether, 8.6% of patients reported experiencing at least one adverse effect following acupuncture. And this could be defined as something as simple as a bruise after acupuncture. And then of all of those patients, 2.2% reported an adverse event which required treatment. The most common adverse effect was either bleeding or hematoma or bruise, and that accounted for more than half of all of the adverse events. The other most common reported effects were pain and what this study calls vegetative symptoms, which sounds scary, but it really just means vertigo or nausea or feeling lightheaded. Of all the patients surveyed, over 229,000 people, only two reported a pneumothorax and only one of those required hospital treatment. There was another study of adverse events conducted in Japan, and this one was published in 2017. This was a much smaller sample size, only 2,180 patients who received in total just over 14,000 treatments. And in this study, adverse events were reported in just over 6% of sessions. And just like in the German study, bleeding and subcutaneous hematoma were the most frequently reported, followed by general discomfort and pain at the needle insertion site. In this study, no serious adverse events were reported, including pneumothorax or any conditions requiring hospitalization. There was another paper published in Taiwan that tracked a cohort of patients between 1997 and 2012. And they looked at over 411,000 patients who underwent over 5.4 million acupuncture treatments. And the incident rates of iatrogenic pneumothorax were 0.87 per 1 million acupuncture treatments overall. and 1.75 per 1 million acupuncture treatments in at-risk anatomical areas, so the upper back or the shoulder. So overall, there's about a 0.001% incidence of pneumothorax following acupuncture, and it's difficult to even find data on rates of pneumothorax caused by acupuncture because there are so few reported. So when a case does happen, especially like the recent case in New York, it tends to get a lot of attention because it is such a rare occurrence. So that's risk number one, pneumothorax, a serious yet extremely rare complication from acupuncture. 

So something else I want to discuss is the risk of infection. Because we do insert needles into the skin, people sometimes have questions about the risk of infection from acupuncture. And the good news is that infection from acupuncture is also very rare. So anytime the skin is pierced with a needle, whether it's an acupuncture needle or a hypodermic needle or a tattoo needle or any other kind of needle, there's a possibility that an infection might occur as a result of microbes being introduced via the break in the skin. And this could come from two sources. One is cross-contamination from a non-sterile needle, and the other is infection from a pathogen that's already present on the surface of the skin and then gets pushed in deeper via the needle. And this is called an autogenous infection. 

Acupuncture needles have been used for thousands of years, and early needles were made usually of stone or bone. Modern acupuncture needles, thankfully, are very different. They're made of stainless steel, they're solid, They are manufactured and packaged under sterile conditions and, importantly, they are designed for single use only. So when an acupuncturist places a needle in you, that needle is sterile. As soon as it leaves your body, it goes into a sharps container and then it's treated as medical waste and disposed of. In fact, we don't even use the same needle more than once on the same patient because we want to minimize the risk of an autogenous infection. So if I put a needle in your leg, I'm not going to remove it and put the same needle in your arm. I'll just use a new needle. In most states in the US, acupuncturists have to complete a training called clean needle technique to become licensed. And this course outlines all the safe practices for needle handling, plus practice for preventing other adverse events like bruising, fainting, and I'll talk more about those in a bit. So there's virtually no risk of cross-contamination or infection from an acupuncture needle. There was a time when needles were reused and practitioners would have to autoclave their own needles and have sort of their own sterile lab. But nowadays, disposable needles are inexpensive and have been widely used since the late 1980s. and in 1995, the FDA designated acupuncture needles as medical instruments. 

In this day and age, every acupuncturist uses disposable needles, so the risk of infection is very, very low. Now, an interesting question that comes up when talking about infection is whether or not an acupuncturist will swab the skin with alcohol before inserting a needle. The current Clean Needle Technique Manual, which was published in 2020, states, quote, alcohol swabbing is recommended but not essential before acupuncture needle insertion as long as an area is clean, unquote. There aren't any studies comparing skin preparation prior to acupuncture needle versus no skin preparation. And the closest information available pertains to skin preparation prior to injections. And most research concludes that alcohol swabbing is not necessary to prevent infection at injection sites. Personally, in my own practice, I don't swab the points with alcohol before treatment unless the skin is visibly dirty. 

A couple of other potentially serious, yet very rare, possible adverse effects of acupuncture are damage to the peripheral nerves or blood vessels. So let's talk first about the peripheral nerves. Sometimes people will ask if acupuncture stimulates the nerves, and as I talked about in episode 12, acupuncture does affect the nervous system, but we don't actually touch the nerves with the needles. At least, we don't intend to. But occasionally, the needle can directly stimulate the nerve. And when that happens, it can be quite painful and there is the potential for some damage to the nerve. This is a very rare occurrence. Again, acupuncturists learn not only where the points are, but how deeply to needle each point and the angle of insertion and the important anatomical structures around each point. And if an acupuncturist is following the guidelines for safe needle insertion at each point, it's extremely unlikely that the needle will actually touch the nerve and cause any damage. Anecdotally, I have heard of a handful of cases of peripheral nerve damage from acupuncture, and it is a condition that does heal on its own, but it's a slow process. From what I could find, there were 5 published cases of nerve injury from acupuncture between 1987 and 2008. Now, these were just the cases published in medical journals. So there were likely more, but from what the literature suggests, it's an extremely isolated occurrence. 

Now, I also mentioned potential damage to blood vessels. So the frequency and severity here really depends on what type of blood vessel we're talking about. It's not all that unusual for an acupuncture needle to nick a small capillary just under the surface of the skin. When this happens, it usually causes a small bump to appear at the site of the needle after it's removed, and usually a bruise will develop. This is a minor condition that resolves on its own and isn't a cause for concern. Occasionally, a needle will puncture a larger blood vessel, and this is usually due to deep needling with a lot of stimulation. When this happens, it can cause more serious complications such as a large hematoma or damage to the blood vessel. This will resolve on its own too, but it takes longer to heal than a small capillary. Damage to any type of blood vessel is pretty rare, even the small capillaries, and you might be wondering why it doesn't happen more often, given the fact that we are inserting needles into the skin, and often doing so in areas where the blood vessels are very close to the surface of the skin. When I was in school, I had a teacher explain it to me this way. Imagine you stick a chopstick into a bowl of noodles. It's unlikely that the chopstick will actually pierce one of the noodles. They kind of slide around and move out of the way. So it's similar with inserting an acupuncture needle. The blood vessels are slippery. They're not fixed in place. So when a foreign instrument is reduced into their environment, they kind of just slide out of the way. And if you've ever had experience getting blood drawn, this makes sense. A phlebotomist has to very carefully insert a needle into your vein in order to draw blood. It's actually rather difficult to puncture a vein with a hypodermic needle. much less a much smaller acupuncture needle. So the risk of blood vessel damage with acupuncture is quite low. 

And one more potentially serious complication I want to mention is damage to other internal organs besides the lungs. I hesitate to even mention this as a potential side effect because it's so rare, but this episode is about all the potential risks and side effects, so I'm including it. There are some documented cases of damage to internal organs from acupuncture. But when we look a little deeper, we see that the risk is so, so low, it's practically non-existent. Why is that? Well, first of all, most of the documented cases are from the mid-20th century, when disposable needles were not widely available, and so practitioners would reuse their needles. The process of autoclaving the needles would weaken them, so it was more common for needles to break. And the majority of cases of organ damage were due to needles that had broken off and migrated to other parts of the body. With single-use needles now being the standard, it is extremely rare for a needle to break. So this risk of migration and breakage doesn't really even exist anymore. Secondly, several of the documented cases of organ damage were due to self-administered acupuncture. And I've said this on this podcast before, but it bears repeating. If you are not a trained, licensed acupuncturist, please do not needle yourself. As I said, our training includes instruction on needle depth and angle of insertion for every single point. When we're following these standards, there's virtually no risk of damage to an internal organ. 

Okay, so those are the more serious potential complications, and next up, I'll talk about the more common but less serious adverse events. But first, a quick word from this episode's sponsor. 

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Okay, so we've talked about some potentially serious but extremely rare adverse effects of acupuncture, including pneumothorax, infection, damage to blood vessels and peripheral nerves, and organ damage. Our profession has many safeguards built in to minimize the risk of these events. One I already mentioned several times is training. Also, there's a lot of testing involved in becoming an acupuncturist. We have to pass multiple comprehensive exams at key points in our education and before becoming licensed. Student internship is another big safeguard. By the time an acupuncturist is licensed, they've already completed hundreds of supervised internship hours, both as observers and hands-on treating patients. So even a brand new acupuncturist already has a lot of practice under their belt. We also have continuing education requirements, which includes ongoing safety training. We take safety very seriously. So if the acupuncturist you're seeing is licensed by their state medical board, the risk of a severe complication from acupuncture is very, very low. 

So I want to move on and discuss the less serious but more frequent side effects of acupuncture. These still don't happen all that frequently, but it's good to be aware of them because if you are going to experience a side effect, it's more likely to be one of these. So first is bleeding and bruising. And I really don't even like to think of bleeding as an adverse event because sometimes bleeding after the needle is removed is a good thing because we think of it as releasing excess heat. It's sort of like releasing the steam valve on a pressure cooker. And in fact, bloodletting is actually one of our treatment techniques. So sometimes we will intentionally cause a point to bleed because we want that therapeutic action of clearing heat or moving stagnation. When bleeding does occur, it's usually only a drop or two of blood. Sometimes more prolonged bleeding will occur if a patient is taking certain blood thinning medications or supplements, and that could be aspirin or Coumadin or a fish oil or vitamin E supplement or anything that is an anticoagulant. 

Bruising at the needle site is another common occurrence. And again, it occurs more frequently with patients on blood thinners. And actually, in Chinese medicine, bruising easily is a sign of weak spleen qi. So when we see a patient who bruises easily, that's a bit of a diagnostic clue for us. When bruising does occur, it's usually just a small bruise right at the site of the needle, and it goes away on its own in a few days. Occasionally, a larger hematoma will appear, and that occurs when a needle nicks a small capillary, as I mentioned earlier. The bruise may be larger, there might be a bump there, and it may last more than a few days. But again, this is something that will resolve on its own and is not a cause for concern. 

Another lesser side effect is pain at the needle site. And similar to bleeding, I don't necessarily think of this as an adverse event. I talked about this a bit in episode 8, but there's a concept in acupuncture called de qi, and that's spelled D-E-Q-I. And it translates to the arrival of qi. And what that means is that, well, the qi has arrived, the needle has been placed, and now the patient's qi is doing something in response. Da qi is an essential part of the treatment. So when we place a needle, part of our aim is to stimulate the arrival of qi. Interestingly, every acupuncturist has their own idea of what de qi means, but it generally is some sort of sensation, felt by either the patient or the practitioner or both. And sometimes, de qi feels uncomfortable. It could be a dull ache or a sharp zing or heat or cold or any number of sensations, but it's good to keep in mind that this type of sensation means that the treatment is working. Now, Dachia is not usually a prolonged sensation. It usually lasts about a minute or so. So pain at the needle site at the start of a treatment is not an adverse event. In fact, it's a good sign. But pain that persists during a treatment and doesn't diminish on its own or even gets worse It's usually a sign that the needle is just not quite in the right place. I tell my patients to let me know if a needle sensation is uncomfortable to the point that they can't relax during a treatment. Usually when that happens, the needle is placed a little too deeply or maybe some muscle fibers have gotten twisted around a needle. It's usually an easy fix just by repositioning the needle. Now, sometimes pain at a needle site will persist after a treatment. This usually isn't cause for concern and it will typically resolve on its own within a day. And while we're on the subject of needle sensations, There is some evidence that consuming caffeine before a treatment can cause more discomfort when the needles are inserted, because caffeine affects pain perception. So if you're needle sensitive or anxious about needles, it's best not to have caffeine before treatment. 

Now related to that is the occasional worsening of symptoms after a treatment. Sometimes this is referred to as a healing crisis. My experience with this is that it usually occurs in the early stages of treatment, it usually lasts for about 24 hours, and it's often followed by significant improvement in symptoms. So if I'm working on someone's shoulder, they might notice more pain and less mobility in the first 24 hours after their treatment, and then after that healing crisis period, their shoulder will feel a lot better. Honestly, I've been doing this a long time and I've never been able to determine a common cause on my end. Like if it's a certain type of treatment, or number of needles, or where I place the needles, or how long I leave the needles in. And truly, what I think is that some patients' bodies, at certain stages of healing and life, just need to go through this process of feeling worse before they feel better. It doesn't happen to every patient, and just because it happens to you once doesn't mean it's going to happen every time. All I know is that this is sometimes a necessary step in healing. And fortunately, it's a temporary one. Now, occasionally, a person will feel worse beyond the 24-hour period after a treatment. And this could be a sign that something more serious than a healing crisis is going on, perhaps one of those more serious adverse events I mentioned earlier. You should always just contact your acupuncturist if you're feeling much worse for more than a few days after a treatment. 

And one more potential lesser adverse event with acupuncture is lightheadedness or fainting. Fainting as a result of acupuncture is very rare. Lightheaded or dizziness is a little less rare, but still not that common. And this usually occurs if the patient hasn't eaten anything in a few hours before getting a treatment. So their blood sugar is already low. This can also occur if a patient is nervous or if the practitioner does excessive stimulation. Also, sometimes a person might feel a little drowsy after a treatment, and if they just sit and rest, they will usually feel fine after a few minutes. Okay, so I want to end with a little perspective here. I've talked about a number of potential adverse events from acupuncture, all of which are rare. Some, like a pneumothorax, are exceedingly rare. And the ones that are more common, but still infrequent, are transient and will resolve on their own, like a bruise or discomfort. 

Now, let's compare this with the potential adverse events from other types of medical care. The side effects they rattle off in those commercials for pharmaceutical drugs are enough to give anyone pause about taking prescription meds. And in addition to side effects, there's also the potential for drug overdose or drug addiction. With a hospitalization, you have the risk of infection, the risk of the wrong treatment being administered, the risk of post-procedure complications. Now, I'm not trying to rail against Western medicine, and I'm certainly not trying to encourage anyone to stop taking their meds or go against medical advice. Every form of medicine has its risks. and it's administered by humans who sometimes make mistakes. But the risk of acupuncture compared with other forms of medicine are very, very low. 

And there's one more thing I want to point out. I like to say that acupuncture has very few side effects, but it has a whole lot of side benefits. And what I mean by that is when you get acupuncture, You'll often notice that lots of little things in your life start to feel better. Maybe you go to acupuncture for help with shoulder pain, but then you also start to sleep better, or you have more energy, or your mood feels more even-keeled. Acupuncture works holistically. We don't compartmentalize your shoulder from the rest of your body. So inevitably, some of those points we're using for shoulder pain are going to work on other things too. Or if you've got shoulder pain in the scapula, that's the small intestine channel. And the small intestine is paired with the heart. And the heart is the center of your emotions and houses the spirit. So to an acupuncturist, it totally makes sense that you're sleeping better and feeling more calm when we're working on your shoulder. It's all connected. So to recap, very low risk of adverse effects from acupuncture and lots of side benefits. So go get some acupuncture. 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.