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Acupuncture for Our Nation’s Pain and Opioid Epidemics- My Two Cents

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According to recent estimates, as many as 100 million Americans suffer from some degree of pain on a regular basis. Chronic pain (pain persisting for > 3mo) is particularly disabling and is significantly associated with loss of productivity, substance abuse, and depression.

Conventional pain management strategies typically involve medications and/or invasive procedures, but “fixing” pain is seldom as simple as merely administering a pill, anesthetizing the source or replacing a defective body part. Pain often has its origins in maladaptive lifestyle habits (lack of exercise, too much exercise, poor diet and sleep habits, overwork, poor body mechanics, etc) and life stresses. Furthermore, chronic, persistent pain often relates to biomechanical stresses resulting from protective adaptations to discomfort and to inactivity (due to fears that exercise will make pain worse). Factors involved in the genesis and maintenance of pain must be addressed when possible.

While pharmacologic therapy can be appropriate for management of pain, it frequently is ineffective (particularly for chronic pain) and is often associated with troublesome medication side effects. Opioids, the traditional “go to” option when less potent analgesics have failed, may be useful for acute pain but the efficacy of opioids for treating chronic pain has not been established and chronic opioid use poses significant risk for addiction.

Unfortunately, opioid addiction is a very real problem in the United States today and sadly, legally prescribed narcotic pain relievers are all too often the gateway to addiction.

Cracking down on opioid abuse, restricting the prescribing of opioids, and making narcotic overdose antidotes more widely available (as the FDA and CDC have suggested) address the opioid problem but do nothing to solve our nation’s pain problem.

Interventions for pain, such as injections into spinal nerves, nerve deadening procedures, implantation of spinal cord stimulators, and major surgeries often provide only temporary relief of discomfort, may be ineffective and at worst, can sometimes exacerbate the very pain they are employed to treat. These procedures are also expensive and because they are “invasive”, confer risks of infection, organ damage and even death.

Clearly we need to partner with our patients in their own pain management and we need more effective, lower risk strategies for treating pain

And this is where I believe acupuncture can play a key and valuable role.

The benefits of acupuncture were first documented in the Western world in the early 1800s when European physicians learned of the technique and began experimenting with it and reporting successes in the treatment of pain. In 1826, Benjamin Franklin Bache, grandson of Benjamin Franklin, reported in the North American Medical Surgical Journal on 12 patients from the Philadelphia prison system whom he treated for various chronic pain conditions with “acupuncturation”. Bache’s technique involved inserting needles locally at sites of pain and thus was distinct from the meridian based traditional Chinese approach, but was acupuncture nevertheless (and incidentally more akin to my own approach). Case histories and treatment protocols were recorded meticulously and the majority of the patients had either complete or partial resolution of symptoms, with benefits maintained at 3 month follow up visits. But despite Bache’s work and numerous favorable reports in the medical literature between 1800 and 1840, acupuncture never garnered widespread attention and by the mid 1800’s, had almost completely faded from Western attention.

There were probably several reasons for this: First, the notion of inserting needles into the body to relieve pain was counterintuitive; second, the development of

laudanum and surgical anesthetics ushered in the era of modern pharmacology with the promise of pharmaceutical solutions for pain; third, the failure to advance a plausible scientific theory to explain acupuncture’s mechanisms of action hampered its acceptance in the medical community.

In many respects, the advancement of acupuncture is still hindered by the same obstacles.

Consider that a study published in the Archives of Internal Medicine in 2012 showed acupuncture to be effective for treatment of a variety of chronic pain conditions. Yet despite the findings of this study and a large body of additional supportive research, physicians seldom consider recommending acupuncture for pain and fewer than 10% of Americans have tried acupuncture.

Lack of coverage by insurance carriers is certainly a major factor in the underutilization of acupuncture but it is also human nature (exploited by the pharmaceutical and medical industries) to want quick fixes for our problems with a minimum of personal investment in the process. And pharmaceutical companies and purveyors of interventions often promise quick and easy results.

While no one knows precisely how or why acupuncture works, I believe strongly that its benefit derives from the fact that it marshals the body’s innate self-healing defenses.

And as a physician acupuncturist with a practice devoted to treatment of pain, I can testify that acupuncture works, often amazingly well, for a great many conditions including headaches, neck pain, lower back pain, shoulder pain, and tendonitis to name a few.

But in my experience, acupuncture achieves best results when utilized relatively early in the course of pain, in conjunction with appropriate lifestyle changes and a regime of regular exercise. And such an approach makes sense because it promotes self-management of pain as opposed to an approach where drugs are employed to mask pain or where the doctor plays the role of a mechanic whose job is to “fix” the patient.

At a cost of $75-100 per treatment, and with most insurance companies not covering the cost, many are put off by acupuncture’s price tag. But fewer sessions are needed when acupuncture is employed early in the cycle of pain and with such a strategy, most clients would actually SAVE time and money in the long run with considerably less suffering.

In summary, we have a chronic pain problem in the United States today and secondarily (from relying too heavily on narcotics for management of intractable pain), we (the medical and pharmaceutical industries) have helped to create an opioid crisis.

It is clear that we need to change our approach to managing pain. I do not believe the solutions lie in new and improved drugs or more complex medical interventions. Rather, we (the medical community) must advocate for our patients to become more invested in their own health by encouraging healthier lifestyles and promoting self-care. And when pain does occur, we must look for and address the root causes, and when possible, act to prevent the transition of acute pain to chronic pain. And if a little help is required in that effort, the low tech 2000 year old healing art of acupuncture may be the best tool in the toolbox.

Michael D. Martin, M.D.

It’s All About Balance Folks

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When I completed my training in acupuncture 2 years ago, I believed I had absorbed everything I needed to know about traditional Chinese medicine.

My interest was in learning to treat pain and other health conditions using techniques which facilitate self-healing, and with acupuncture, I was satisfied that I had found an effective means.

Truth be told, the rest of traditional Chinese medicine seemed irrelevant and outdated. After all, modern scientific explanations of acupuncture’s mechanisms of action had (in my mind) supplanted the ancient notions of “blocked Qi” and “imbalances of yin and yang” as causes of illness. How could I put any stock in such concepts that were neither quantifiable nor amenable to proper scientific investigation?

But in my focus on memorizing acupuncture point locations and learning proper needling technique, all the while working to reconcile my new knowledge with modern science, I had failed to grasp the philosophical underpinnings of the material I was learning.

Six months ago I became enlightened. In preparation for a lecture series I was to deliver on acupuncture, I began to research its history in depth. And as I learned more about the principles of ancient Chinese medicine, I found great wisdom which resonated with me.

Understand that Chinese medicine did not arise as a discipline unto itself, but rather as part of a broader attempt to explain the natural order of the universe and man’s place in that order. And what the ancient Chinese observed and were impressed with, was a world of rhythmic cycles and dynamically balanced opposites (e.g. day and night, summer and winter, male and female, etc). Man was considered to be a microcosm of the macrocosm of the universe and as such, it followed that balance was essential to health. Taoist influence featured heavily in the foundations of Chinese medicine, and being in harmony with the Tao (the “way”) meant living in harmony with the rhythms of nature.

Consider the following passage from the historic text, “The Yellow Emperor’s Classic of Medicine”, in which the legendary “Yellow Emperor” Huang di seeks counsel from his wise court minister Qi bo:

Huang di: “I have heard that in the days of old everyone lived 100 years without showing signs of aging. In our time, however, people age prematurely, living only 50 years. Is this due to a change in the environment, or is it because people have lost the correct way of life?”

“Qi Bo: “In the past, people practiced the Tao, the Way of Life. They understood the principle of balance, of yin and yang…They ate a balanced diet at regular times, arose and retired at regular hours, avoided overstressing their bodies and their minds, and refrained from indulgence of all kinds. They maintained well-being of body and mind; thus it is not surprising that they lived over one hundred years.”

“These days, people have changed their way of life. They drink wine as though it were water, indulge excessively in destructive activities, drain their body’s essence and deplete their Qi… Seeking emotional excitement and momentary pleasures, people disregard the natural rhythm and order of the universe. They fail to regulate their diet and lifestyle and sleep improperly. So it is not surprising that they look old at 50 and die sooner.”

Incredibly, these words were written over 2000 years ago, yet remain as applicable today as when they were first set down in print.

Balance is indeed critical to health. Modern life is complex and fast paced and most of us find ourselves feeling out of balance at some point. Too often we try to correct, not by moving closer to our centers, but by offsetting our stress with something equally extreme in the opposite realm. Too much work-> Play harder or squeeze more out of our days by sleeping less, exercising more (or less), eating more, buying expensive toys, taking vacations we can’t afford, or self-medicating to relax. The results are sleep deprivation (with its negative effects on immune system and mood), overuse injuries (from over-exercising), obesity, financial stress, stress related ailments such as headaches, drug and alcohol dependence, etc. All too often, we feel as though we live our lives on teeter totters, see-sawing back and forth, chasing the elusive balance while actually getting farther and farther from equilibrium.

It may surprise you to know that acupuncture was originally employed primarily to maintain balanced health (i.e. either in a preventive fashion or utilized very early in the course of an illness as opposed to using it to treat advanced illness). The ancients believed that acupuncture worked by restoring normal flow of Qi (vital energy) in the body. It was understood however that this could only be effective if the imbalance in Qi flow was not chronic and severe, and if destructive lifestyle factors were corrected in conjunction with treatment.

Even with a modern interpretation of acupuncture’s mechanisms of action, it is obvious that acupuncture is much less likely to be successful in the treatment of an ailment without correction of precipitating factors or lifestyle habits that contributed to the malady. As an example, acupuncture can be quite effective for tennis elbow pain, but long range success depends on modifying the precipitating activity, along with stretching and strengthening the involved muscle.

So what role can ancient Chinese philosophy play in the world of modern medicine?

Advances in Western medicine over the past 100 years have been nothing short of miraculous, and modern diagnostics, innovative pharmaceuticals, and high tech interventions have saved countless lives. We owe this to the scientific revolution and more specifically to the scientific method of investigation.

But therein lies both the strength and weakness of Western medicine; as it has become increasingly wed to technology, the human aspect of medicine has gotten pushed aside, while our increasing faith in the powers of pharmacotherapy and medical science has taken us (patients and physicians alike) farther and farther away from notions of self-healing and personal responsibility for health.

And so it is that the observational wisdom of the ancient Chinese philosophers can help to bring us “back to our centers”, where we feel grounded and in charge of our own wellbeing.

Eastern and Western medical traditions reside on opposite sides of the same coin and both have relevance and value.

In the end, it’s not about which discipline is best for your health, it’s all about balance folks.

 

Michael D. Martin, M.D.

 

 

Yes I Do Medical Acupuncture and No I’m Not Crazy

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About a year ago, shortly after I gave up primary care to start an acupuncture practice, I attended a social gathering of physicians in my community. I was eager to mingle with my peers and share the news of my new career, and I envisioned a universal embrace for my new venture. After all, I live in the progressive city of Austin and with millions of Americans suffering with chronic pain and desperate for relief, I, a respected internist with a new skill, was poised to offer an alternative to opioids and invasive procedures.

My delusions of grandeur collided with reality about 5 minutes into the evening.

I had grabbed a beverage and was chatting amiably with a young fellow who had just moved to Austin to start a plastic surgery practice. We were having a nice dialogue when up walked another doctor who introduced himself and shook hands with each of us. He inquired of my new friend as to his specialty and paid appropriate homage to the response. Turning to me, he asked, “And what do you do?”

“I do medical acupuncture,” I answered smartly.

“Hmm,” he said with a faint nod. Based on his expression, a casual observer might have hypothesized that I had just told him that I was recently released from prison. Without further ado, he turned back to my surgical colleague and began a conversation that did not include me. I shook it off and ambled away to find another conversation. The rest of the evening went something like this: “Acupuncture eh? I think my cousin’s wife tried acupuncture for her back pain but I’m not sure if it helped.” No questions about the science of acupuncture or how or why I entered the field. Nothing hostile mind you, just a general lack of interest.

Finally, my confidence shaken, I slipped away and shuffled off to my car, pondering the events of the evening and mulling over the feeling of being an outsider. I mean, it’s not like I was dressed in a Nehru jacket with a medallion around my neck. I was wearing dress slacks, a button down oxford, and a blue blazer for gosh sakes. No, it wasn’t my attire. It was the acupuncture.

I shouldn’t have been surprised, given that 5 years earlier I probably would have had a similar reaction to a colleague “going holistic”. But the fact is that after researching acupuncture extensively and then going through training, I was so convinced of its benefits that I was overflowing with eagerness to spread the word. I was certain that all my colleagues needed was the benefit of my knowledge to bring about enlightenment.

Unfortunately I had grossly overestimated my power to change the medical community’s attitude about acupuncture.

Physician reluctance to embrace acupuncture is completely understandable. The ancient Chinese approached health and wellness from a philosophical rather than scientific direction. There is both beauty and wisdom in this approach (more on this subject in future musings) but the paradigm is completely foreign to the Western mind. Notions of universal vital energy and illness due to “blocked Qi” are not rooted in science, and when acupuncture’s mechanism of action is explained as restoring or re-balancing the flow of vital energy in the body, most physicians justifiably tune out.

Additionally acupuncture research leaves much to be desired. Methodologies are not sufficiently standardized among studies and so results of clinical trials can be difficult to interpret and compare. And then, because many studies show that “sham” acupuncture is nearly as effective as true acupuncture, there is that “So it’s all placebo” assertion that just won’t go away.

But the facts are that basic science research over the past 50 years has confirmed a number of measurable effects of acupuncture, including release of endorphins, serotonin, norepinephrine, and cortisol, plus a variety of other actions that can modify the experience of pain and stress. Research also shows us that inserting needles anywhere on the body will produce some of the same effects as needling at “true” acupuncture points. Thus “sham” acupuncture (which typically involves inserting needles a couple of inches away from traditional points) is not a true placebo intervention. Animal studies further negate the placebo hypothesis (i.e. animals respond favorably to acupuncture and laboratory animals are not subject to placebo response). And ample research supports acupuncture’s benefits for chronic pain and a host of other conditions.

I don’t believe in Qi or in re-balancing energy flow along invisible meridians, but I do believe in acupuncture. It’s not a replacement for western medicine nor is it a treatment to be applied indiscriminately. But it is a valuable tool in the medical toolbox and when used appropriately in an evidence based fashion, it can produce some remarkable results. Its value deserves recognition by insurance companies as well as by the medical community.

And so I will continue my efforts to enlighten my colleagues about acupuncture while advocating for better research and working to insure that acupuncture gets the respect it deserves as a legitimate therapeutic intervention. This will take time but the fight is worth it. I am certain.