Last month, there was a National Institute of Health consensus conference on acupuncture to evaluate the scientific evidence supporting the use of this ancient technique in modern medicine. The panelists concluded that acupuncture is effective in the relief of post-operative pain, chemotherapy-induced nausea and vomiting, nausea of pregnancy, and post-operative dental pain. Although the scientific evidence is less convincing, stroke rehabilitation, headache, addiction, menstrual cramps, tennis elbow, fibromyalgia, low back pain, carpal tunnel syndrome and asthma were listed as conditions worthy of further investigation.
Last year the Food and Drug Administration set the stage for the NIH conference by officially approving acupuncture needles as non-investigational medical devices. Panelists at the recent conference recommended broader public access to the technique which should lead to reimbursement for acupuncture by the government and insurance companies. Some West Coast managed care companies already include acupuncture as a covered service, and it is estimated that about $500 million is spent each year by the more than one million Americans who visit acupuncturists.
Most states have formal licensing for non-physician acupuncturists who have completed several years of training at an acupuncture school. Physicians may learn acupuncture through a continuing medical education program offered by UCLA, but usually have considerably less training and experience than practitioners of traditional Chinese medicine who may also be skilled in the use of herbal remedies. North Carolina established state guidelines for acupuncture in 1992, and there are currently two physicians on the Duke faculty trained in acupuncture.
As the public demand for acupuncture increases, it is important for Medical Center staff to be aware of the considerable scientific evidence that already exists on the subject. Most skeptics are usually unfamiliar with the large amount of basic animal research that has been performed and do not realize that acupuncture is a commonly utilized technique in veterinary medicine where the placebo effect is less likely to be a factor. Although the exact neurophysiological pathways are not fully understood, an endorphin mechanism is suggested by the fact that pain relief is diminished when naloxone (a morphine antagonist) is administered prior to treatment.
Given this effect, it is not surprising that one of the most promising indications for acupuncture is in the treatment of addictions. Psychiatrist Dr. Michael Smith pioneered its use in New York City in the '80s, and there are now dozens of acupuncture detox clinics in major cities around the country patterned after his program. The Chinese model for addiction, upon which the treatment protocol is based, is one of "empty fire" in which the addict displays considerable superficial energy, but lacks any inner substance.
I visited Dr. Smith's clinic in 1989 and was amazed to see over 200 addicts a day pass through its doors. Most were mandated by the city courts to receive their treatment there, and New York City actually changed its acupuncture laws to allow his drug counselors to be trained to place the five needles in each ear required for treatment. Addicts would be quite agitated upon arrival, but appear rather mellow after half-an-hour of auricular acupuncture and a glass of herbal tea.
Research done at the University of Minnesota has validated the effectiveness of the technique and led the NIH to give that institution a $1 million grant to study alternative treatments for addiction. The first research on the subject at Duke was done by a third-year medical student in 1996 in collaboration with a Raleigh auriculotherapist who specializes in smoking cessation. Future directions for research may involve high-tech neuroimaging procedures which have recently been used at the University of Pennsylvania to study the effects of acupuncture on important centers in the brain.
So, with all this mainstream science gaining recognition, where does the Eastern concept of "chi" fit into this discussion? The stimulation of acupoints with needles, lasers, electricity or massage is thought to unblock the flow of this vital energy along the meridians. The existence of the points can be confirmed electrophysiologically as specific foci of decreased skin resistance. Although many points are located near to where nerves penetrate muscles, no specific anatomic correlations have been made, and chi has never been scientifically measured in a reproducible fashion.
The vital force remains a metaphorical form of subtle energy which has been called by many names in many different cultures of the world. The best evidence for its existence is in the results produced by the techniques used for thousands of years to bring it into balance. Scientist and mystic Pierre Teilhard de Chardin notes in "Human Energy" that "This energy is probably incapable of measurement, but is very real all the same, since it gains a reflective and passionate mastery of things and their relationships."
Dr. Larry Burk is an associate professor in the Department of Radiology.
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