The power of patient expectations

This recent article touts the power of patient expectations in the effectiveness of acupuncture. The author summarizes the study:

In analyzing the patients’ responses, the researchers found: “In our four randomized trials, patients with high expectations were more likely to report better outcomes than patients with lower expectations, both after treatment and four months later. The size of expectation effects is … clearly clinically relevant. This effect was observed both in patients receiving the ‘true’ and the minimal acupuncture.”¹ In fact, for patients with migraines², the number of patients who reported improvement was almost 60 percent and did not differ between those who got ‘true’ acupuncture and those who got “minimal [or sham] acupuncture.”

In examining this interesting phenomenon further, they speculated that perhaps a nurturing environment helps foster this positive attitude: “Intense and frequent provider-patient interaction, touch, needling pain, and an ‘exotic’ framework could make acupuncture a strong ‘ritual’ which is associated with stronger expectation effects than other interventions.”¹

Another possible explanation is that positive expectations can modify pain receptor pathways in the brain. As the researchers noted, “There is clear evidence from research on placebo analgesia showing that, in principle, expectations can modify pain perception in the brain. Several lines of research indicate that expectations associated with the application of placebos activate endogenous opioid systems, however, non-opioid pathways are also likely to play an important role … In summary, expectations of clinical benefit seem in general to be a major mechanism of placebo effects.”¹

The author then concludes:

Clearly, these study findings seem to emphasize that fostering a positive patient attitude toward acupuncture and Oriental medicine can have a pronounced influence on clinical outcomes. If patients understand and appreciate AOM, that alone might contribute to healing as much as the actual acupuncture procedure itself.

I am certainly all in favor of creating a nurturing, positive doctor-patient interaction. However, this should be no reason for cheering among acupuncturists. The combination of environment, expectations, and a non-specific opioid effect in the success of treatment is none other than the placebo effect. This is not to say that such body-mind interventions are not therapeutically desirable. They certainly are. However, there are a couple of thorny issues here. Since acupuncture is a very expensive form of treatment whose effects typically disappear at some point after treatment is discontinued, it is important that it is determined what mechanisms are truly at play so they may be incorporated into mainstream care without significant costs to providers or patients. In addition, a number of court rulings have made it clear that no therapy, no matter how effective, may be employed on a patient if deception is a factor.

If a provider knows that his treatment method is a placebo, but he pretends it is something other than that, he has committed both an ethical and criminal violation. It is called fraud. What this study and others like it suggest is that a method inducing a state of relaxation, suggestion, and non-specific opioid effects can have health benefits. If patients are told that this is what is happening to them when they see an acupuncturist instead of being handed some mystical mumbo-jumbo, that then obviates the issue of fraud. However, insurers should still only be expected to pay for such a therapy if there are no cheaper and equally effective alternatives. In fact, it is likely that guided relaxation, yoga, and meditation can yield similar results. Such therapies are not only cheap to administer, but patients can learn to do them on their own, resulting in long-lasting benefits. One of the reasons that acupuncture effects are short-lived is that they are passive on the patient's part. The patient will benefit more from an active approach to wellness. Acupuncturists, of course, have a vested interest in telling their patients otherwise, so caveat emptor.