Question:If we step out of our career world for a moment, there are still a percentage of Americans that truly believe that Acupuncture therapy is hocus pocus, placebo induced, voodoo, etc.   Say for a moment you were at a cocktail party and you were in conversation with one of these people.  What would be your “cocktail party” answer to the question   “Acupuncture?  Does that really work?”

Answer: An important aspect of going to an acupuncturist involves what I refer to as the setting effect.  This is related to the placebo effect, but has some differences.  In a true placebo effect, the person does not know what it is that they are taking (here, I’m talking about a drug setting).  They simply observe what happens afterwards.  If they get a headache afterward, that is reported, and the headache being reported as occurring after taking the pill puts it down as an “effect” even if there is no mechanism.  Some people think that placebo effects have something to do with believing that a remedy will work.  There can be some of that.  Placebos have a high level of “activity” in treatment of pain, and I suspect that because pain is so complex, and involves how we interpret the pain signals, that a belief that a remedy has been taken may be sufficient to change the perception of pain.  The setting effect is a much bigger effect.  For purpose of discussion, we will assume that an acupuncture treatment itself does nothing to the flow of qi and blood or releases endorphins, or anything like that.  In other words, from some kind of mechanistic stance, we would say it has no effect.  Now, the first thing that happens is a person has decided that they need to change how they are handling their disease or symptom.  By deciding to get acupuncture, they are making a mental adjustment.  They are being open to it having an effect, some people enthusiastically so, others (perhaps pushed by a relative to get acupuncture) with great hesitation or suspicion. The very shift in the consciousness about the disease and its possible treatment already begins to have an impact on the individual.  Their decisions and actions may shift, even if slightly, even before getting the treatment, in anticipation of a possible success.  When they encounter the acupuncturist, they now will get drawn into the different medical system.  They may be listening to Oriental background music, and see artworks of Chinese nature; the practitioner, not usually dressed like an M.D., may ask about preferences and look at their tongue, feel the pulse, etc.  This is a new world, and unless there is tremendous resistance (which there is at times), it has an effect.  Now the person is to lie down (in some cases sit), and feels these strange sensations of needle sticks that are not quite pleasant but not so bad as the hypodermic needles that are remembered, and there are the strange sensations that we call “deqi” or even a sense of movement from one needle to another or along the arm or leg. All these peculiar sensations stimulate the mind, just as any other strange experience.  Now, the practitioner leaves the room and one lies there with these sensations in a relaxing setting (hopefully relaxing; the needles can be very uncomfortable for some).  When  was the last time in the middle of the day I just lay down and rested like this?  It is like a special meditation session. Now the practitioner comes back and removes the needles, calmly asking how I am doing, and I feel as though something has changed.  I’ve turned a corner.  During the next hours, perhaps the next days, I wonder if this or that sensation or experience might be related. I begin to think somewhat differently about some of my activities, what I’ve been eating, how I’ve been reacting.  What was that about my stagnated liver qi?  So, acupuncture has had an effect even though it had no effect.  This is the setting effect.  It is rather powerful.  You can get a little of it deciding to buy a dietary supplement and take the pills each day, but nothing quite like this.  Even if acupuncture doesn’t work, it works.   The setting effect is all the stronger if the practitioner, being very knowledgeable about medicine, helps inform the patient about the disease that is suffered, and conveys means of resolving it, either directly or simply by implication from how it is explained; these are means that the person might take up himself (herself).

Aside from these setting effects, there are potential mechanisms for other kinds of impact.  While in the TCM world we speak of flow of qi and blood in the meridians, to put this into terms more common to our social setting, we may stimulate nerves that affect the brain that, in turn, affect various body responses.  It is sad, in my way of viewing all this, when I hear qi described as electromagnetic energy, or even some kind of mysterious energy, because that has nothing to do with the TCM description and also has nothing to do with modern scientific approaches.  As to the latter, I’ve mentioned just one, about the nerves, and most acupuncturists are familiar with others that have been proposed.  The main point, however, is that those peculiar feelings when the needles are inserted, not so much the tiny sting of the needle entering the skin (which is quite tiny with the needles used in the U.S.), but the various sensations that are attained at the needling site and also any “transmitted” sensations, represent an interaction of the needle with a set of nerves.  Those interactions are known to us because they have made their way to the brain.  If the only impact is that the brain records an unusual sensation, then there isn’t much to go on, but if the selection of certain needling sites (points) and collections of sites (point formulas) has a more specific impact, then the brain can be prompted to do a remarkable number of things to help with healing.  There can be a mechanism, like this one, that explains a response to acupuncture treatment.

My usual suggestion regarding acupuncture is that if a person is open to it as of potential benefit, then if a series of about 6 treatments (in short order, hopefully at least twice a week) are undertaken, that person should be able to tell whether or not a significant effect is likely to occur, and thus decide reasonably whether to continue or not.  That is to say, the perceived effect of the therapy will either be that it is helping (so, it should be continued), or not having an effect; if there is no perceptible effect, then the seventh treatment probably won’t produce one either.  Certainly, for many symptoms and diseases, the number of treatments that should be undertaken is much larger than these six, but I think if someone wants to know how much time and money they need to invest to decide if this will help, here is a means of calculation.

Ideally, at this cocktail party, when challenged about acupuncture, as you speak up to make a few comments, some one will jump in with a personal story about how much acupuncture did for them.  That is always a nice touch.  But, it can happen that someone will jump in and say: “I tried it and it didn’t do anything, it was a waste…”    At which point you have to admit that not all practitioners have quite the skills that would be desired.

Question: Many American patients oddly enough have a strange aversion to using natural botanical plants as medicine, preferring medicines synthesized in a laboratory.  What steps must be taken as practitioners and as  a profession to overcome these fears and objections?

Answer: For me, there is nothing odd about this.  While I am a lover of nature, and also of traditional society, many people are not in that mindset.  To speak of “medicines synthesized in the laboratory” is really do misunderstand what drugs are all about.  It is almost as if to say: why would anyone take something synthetic, rather than to ask why would someone take a drug that was developed by the efforts of dozens of dedicated people?.  Why, then, would anyone use a stainless steel acupuncture needle (a totally synthetic item) and stick it in someone’s body (a very unnatural act), when, instead, a person could do something much more natural?    Rather, one should ask, why would someone get acupuncture?  Drugs were originally isolated from plants.  The first one was morphine from opium poppy.  This was a miraculous development, and anyone who has had a serious injury and gotten a morphine injection knows what I mean.  One of the biggest drug developments was aspirin.  This was taken from an herb material (meadowsweet), but the original substance was found to be too irritating to the stomach.  By acetylating the molecule, it retained all its beneficial effects (some of which are still be discovered) while reducing greatly its irritant effects (there are some who still can’t tolerate it, but this drug is so widely used it is truly amazing).  Meadowsweet cultivation just couldn’t meet the demand, and is an reliable supply source (originally found in Europe, two world wars occurred over its territory since it became a drug).  The synthetic material is a plant drug, as far as I’m concerned, and if I, an herbalist, had a choice between meadowsweet tea, with its variable amount of active component, and a simple tablet of aspirin, I’d choose the latter, not because it is better (it isn’t), but because it is not worse.

What has happened over the years is that more and more powerful drugs have been developed to deal with more and more serious conditions.  Too many of the drugs are being used to deal with lifestyle choices and efforts to ward off death and disease: drugs for forcing the blood pressure down; drugs for dropping cholesterol; drugs for driving down excess blood sugar, drugs for dealing with lives out of control, including psychotropic medications (don’t get me wrong; there are people who may need these drugs for reasons other than lifestyle, but I am here only trying to address this one issue).  On average, Americans over 65 years of age are taking four prescription drugs.  Some are taking eight or more.   And this is not including Viagra and the like.   Young people are taking lots of drugs; some are using illegal drugs, and some are using anti-depressants, appetite control drugs, birth control pills, and so on.  We are a drugged society.  This has something to do with the potency of drugs; if they didn’t have such powerful effects, people would not turn to them.  But, the issue of them being synthetic should not be the focus of our concern.

Many people get the impression, that they can simply substitute, one for one, a nice natural side-effect free herb or formula for a drug.  Once in a while this works, but most of the time it doesn’t.  In ancient China, they used lots of toxic ingredients.  Only recently, cinnabar and realgar, two very popular agents, were removed from patent medicines when it was widely disclosed that cinnabar is a mercury compound and realgar is an arsenic compound.  Traditional Chinese herb formulas frequently had heavy metals, as intended ingredients, and herbs that have proven toxic to the liver (less often, toxic to the heart or kidneys).  Today, these ingredients are weeded out and we mainly use substances that have gentle effects.  Indeed, most Americans are quite fearful of the side-effects of high dose Chinese herb formulas as used in China, causing such conditions as dry mouth, dizziness, and nausea.  So, we use low doses of the mild herbs, and they have very good health benefits, but much less effect (in most cases) than the drugs.

Fears of natural products are partly justified.  Some products simply claim too much (we call it “hype”) and don’t deliver, so the real fear is wasting money.   Sometimes, herbs have had damaging effects; these were mainly rare reactions that were only detected when a large number of people used the herbs.  The same thing happens with drugs: a drug is approved, seems to be doing well, then is pulled from the market after some rare but very serious side effects are discovered from the large number of people taking them under many circumstances.  Sometimes it is just a matter of not knowing what is in the bottle or box: if it is not FDA approved, how do we know that it contains what it says it contains?   Then, as per the above, there were reports of heavy metals in Chinese patents (and also in Ayurvedic herbs), and worries about other contaminants. There are several reasons for concern.

Question:Many patients have great fears about using natural plant medicinals in combination with pharmaceuticals.  What would you say to these patients to both accurately acknowledge their concern but explain the approach to using these two types of medicine in combination?

Answer: The interactions of drugs with drugs is very well publicized, because there can be serious consequences.  If you just watch TV and hear drug ads, they will usually include: “tell your doctor about any drugs you are taking…” and sometimes with a warning about specific potential for problems.  What people need to know first is that the main interaction that could occur between an herb and a drug is that either the herb can make the level of the drug in the blood stream higher than it would otherwise be, or it could make the level of the drug lower than it would otherwise be.  A higher drug level might turn out to be good for relieving symptoms or treating a disease, but it could also be harmful if the drug level is already close to causing side-effects and then a slightly higher level does produce those adverse effects.  A lower drug level might be good for reducing side-effects of a drug, but could drop the drug dosage below its effective level, allowing a disease to have its adverse consequences.  Herbs and drugs don’t interact chemically to make something toxic to the body; rather, the interaction just has to do with the quantity of drug in the blood stream at any given time.

Fortunately, the number of actual herb-drug interactions reported is quite small.  That doesn’t mean that more cases don’t occur, but in general, any such interactions are most often of no clinical consequence: nothing is observed.  The herb that has caused most of the reported interactions is St. John’s Wort, and that herb is not used in Chinese medicine (in fact, it is listed in some comprehensive Chinese herb books, but just very rarely used in Chinese medicine practice).  The drug that has been associated with most of the reported interactions with herbs is Coumadin (Warfarin); blood thinners, as a general group, have been cause for some worry about interactions, but Coumadin takes the lead by far.  I recommend avoiding St. John’s Wort when concerned about herb-drug interactions, but for those on Coumadin, I recommend continued testing of the blood coagulation simply to make sure there is no evidence of any problem.   In addition, when people are taking more than one cardiac drug to regulate cardiac function (so, this would not include lowering cholesterol, which is involved in cardiovascular risk, but not in heart functions), that extra care be taken in using herbs along with the drugs, because in this case even slight changes in drug levels might be a serious matter.  This doesn’t mean herbs can’t be used, but it does indicate that careful monitoring must be maintained.