Credulity about acupuncture infiltrates the New England Journal of Medicine

When people think of the New England Journal of Medicine, they usually picture stern editors, hard data, and the sort of scientific rigor that could sand the varnish off a mahogany table. What they do not picture is a gentle editorial drift toward wishful thinking. Yet that is exactly why critics pounced when NEJM published a widely discussed review on acupuncture for chronic low back pain and seemed, in their view, to give a velvet-roped entrance to a therapy whose evidence remained stubbornly messy.

The phrase “credulity about acupuncture infiltrates the New England Journal of Medicine” captures a specific frustration: not that acupuncture exists, not even that it is studied, but that a top-tier medical journal might describe it with more confidence than the evidence deserved. For skeptics, that was the moment when caution briefly left the building, grabbed a robe, and wandered into the spa.

This debate is not really about whether some people feel better after acupuncture. Many do. The harder question is why they feel better, how much better they feel, and whether the benefit comes from the specific traditional theory of acupuncture or from the larger ritual surrounding it. Those are not tiny details. They are the whole ballgame.

The article that sparked the outrage

The controversy traces back to a 2010 NEJM clinical review on acupuncture for chronic low back pain. The review acknowledged something crucial and awkward: in several well-powered trials, sham acupuncture performed about as well as “real” acupuncture. That is the kind of result that should make any evidence-minded reader sit up a little straighter.

Why? Because sham acupuncture is supposed to function like a placebo control. Depending on the study, it may involve shallow needling, needling at nontraditional points, nonpenetrating retractable needles, or procedures that imitate the experience of acupuncture without following its classic rules. If real acupuncture does not clearly outperform sham acupuncture, the obvious implication is that the specific theory behind acupuncture may not be doing the heavy lifting.

And yet the NEJM review still suggested acupuncture could be a useful supplement for chronic low back pain. That move infuriated critics such as David Gorski and Steven Novella, who argued that the journal had effectively admitted the specific mechanism was weak while still recommending the treatment anyway. To them, this was not nuance. It was a scientific shrug dressed in a white coat.

That criticism still matters because it highlights a problem that reaches far beyond acupuncture: what should medical journals do when a treatment appears to help in practice, but the specific theory used to justify it looks shaky? Should they celebrate pragmatic benefit? Should they emphasize mechanism? Should they warn readers that ritual, expectation, and clinician attention might explain much of the result? The answer determines whether a journal sounds like a scientist or a publicist.

Why sham acupuncture makes this debate so uncomfortable

Acupuncture is one of those therapies that behaves like a cat in a clinical trial: hard to pin down, mildly offended by the process, and always prepared to slip under the sofa just when you think you understand it. Drug trials are usually cleaner. A pill can be compared with a sugar pill. But acupuncture is a procedure, and procedures are unusually difficult to fake well.

That matters because the ritual itself can be powerful. A calm room, a confident practitioner, repeated visits, physical touch, patient expectation, and the feeling that something precise is being done can all shape symptom reporting. Pain, especially chronic pain, is highly vulnerable to these influences. That does not mean relief is fake. It means relief can arise from factors other than the specific theory that the needles are rebalancing invisible meridians.

A famous 2011 NEJM asthma study made this point with the subtlety of a brass band. Patients receiving albuterol, a placebo inhaler, sham acupuncture, or no intervention reported similar subjective improvement with the active drug, the placebo inhaler, and sham acupuncture. But when researchers measured lung function objectively, only albuterol actually improved it. In other words, people can sincerely feel better without the underlying physiology changing in the same way.

That distinction is central to the acupuncture debate. When trials focus on subjective outcomes such as pain, stiffness, or global well-being, expectations and context can influence results. When trials look for large, consistent differences between real acupuncture and sham acupuncture, the margin often shrinks. Sometimes it becomes modest. Sometimes it vanishes. Sometimes it depends heavily on the condition being treated and the design of the sham control.

This is why skeptics saw the 2010 NEJM review as too generous. If a journal admits sham and real acupuncture often perform similarly, then leaps to a favorable recommendation, it risks teaching readers the wrong lesson. It suggests that if a ritual creates enough perceived benefit, the specifics no longer matter. That may be defensible as a pragmatic stance, but it is not the same as saying acupuncture’s traditional claims have been validated.

Why defenders of acupuncture keep making their case

To be fair, critics do not own the evidence. Acupuncture has not survived in mainstream discussions because every study collapses on contact. Some systematic reviews and randomized trials have found benefits, especially for certain pain conditions. The more serious pro-acupuncture argument is not that every meridian map has been scientifically confirmed. It is that the treatment may provide modest, clinically useful pain relief, particularly when compared with usual care or no treatment.

A large 2012 individual-patient-data meta-analysis in JAMA Internal Medicine is one reason the conversation refuses to die. That analysis found acupuncture superior to both sham and no-acupuncture control groups for chronic pain conditions such as back and neck pain, osteoarthritis, and chronic headache. But the authors also noted that the differences between true and sham acupuncture were relatively modest. That sentence is doing an impressive amount of intellectual lifting.

Translated into plain English: acupuncture may do something beyond placebo, but whatever that something is, it is not a thunderbolt from Olympus. It is smaller, subtler, and possibly mixed together with many nonspecific effects. That is not a mic-drop for either side. It is a murky middle.

More recent trials have added fuel rather than clarity. A 2024 trial in JAMA Internal Medicine reported that acupuncture outperformed sham acupuncture for chronic sciatica from a herniated disk, with benefits that persisted in follow-up. In 2025, JAMA Network Open published a large randomized trial showing acupuncture improved pain-related disability in older adults with chronic low back pain compared with usual medical care. These findings help explain why acupuncture keeps appearing in serious clinical conversations instead of being thrown into the same drawer as crystal healing and magnetic bracelets.

Major U.S. medical organizations have also been more open to acupuncture than hardline skeptics would prefer. The American College of Physicians has included acupuncture among nonpharmacologic treatment options for low back pain. AHRQ evidence reviews have likewise described acupuncture as one of several noninvasive therapies that may improve pain or function for selected chronic pain conditions. The NIH’s National Center for Complementary and Integrative Health says the evidence varies by condition: somewhat promising in some areas, disappointing in others, and often limited by study quality or small effect sizes.

Where the evidence still refuses to behave

If you step back from the trench warfare, the evidence on acupuncture looks less like a clean verdict and more like a crowded airport departures board during a thunderstorm. Some signals are positive. Some are delayed. Some are canceled. And a few are still circling for reasons nobody can explain with dignity.

NCCIH summaries illustrate the problem nicely. For some conditions, such as migraine prevention, the evidence suggests acupuncture may help and may be slightly better than sham treatment. For fibromyalgia, some reviews suggest it may beat sham acupuncture, but the evidence quality is not stellar. For irritable bowel syndrome, acupuncture has not clearly outperformed sham acupuncture. For menopausal vasomotor symptoms, evidence suggests benefit versus no treatment but not a clear advantage over sham. Once you start reading across conditions, the pattern becomes impossible to ignore: acupuncture often looks better than doing nothing, but its specific edge over a convincing placebo frequently remains small, unstable, or condition-specific.

That is exactly why the 2010 criticism of NEJM still lands. Journals should not flatten this complexity into a comforting slogan. “It helps some people” and “its specific theory is validated” are not interchangeable statements. Neither are “reasonable adjunctive option” and “scientifically confirmed mechanism.” When elite journals blur those lines, readers can walk away with more confidence than the evidence actually buys.

The mechanism question that never goes away

Acupuncture also carries a plausibility problem, and skeptics rightly refuse to pretend otherwise. Traditional acupuncture is rooted in concepts such as qi and meridians. MedlinePlus still describes acupuncture in relation to the belief that vital energy flows along meridian pathways and that stimulating certain points can rebalance that flow. That is historically accurate. It is also not a framework that maps neatly onto modern anatomy, physiology, or pathology.

Researchers have proposed more modern mechanisms, including local neurochemical effects, endogenous opioid release, adenosine signaling, and broader neuromodulatory changes in pain processing. Some of these ideas may help explain why needling or sensory stimulation could alter pain perception in certain contexts. But even if some physiological effects are real, that does not rescue the classical point-by-point theory in full. It also does not erase the recurring finding that sham procedures can perform suspiciously well.

So when critics accuse NEJM of credulity, they are not merely being grumpy for sport. They are pointing to a deeper scientific obligation: journals must not imply that a treatment’s traditional explanatory system has been vindicated simply because patients report feeling better after an elaborate clinical ritual.

What NEJM should have said more clearly

A better, sharper editorial approach would have been something like this: acupuncture may offer modest relief for some chronic pain patients, particularly compared with usual care or no treatment; however, because sham acupuncture often performs similarly, much of the benefit may stem from nonspecific effects such as expectation, attention, and the therapeutic setting rather than from the specific traditional principles of acupuncture itself.

That sentence lacks the romance of integrative-medicine brochures, but it has the advantage of being intellectually house-trained. It preserves clinical nuance without overselling theory. It respects patients without misleading them. And it gives physicians room to discuss acupuncture honestly as an adjunctive option rather than as a mystical precision instrument backed by ancient cartography.

The point is not that medicine must reject any therapy touched by placebo effects. In pain care, nonspecific effects are everywhere. The point is that a journal’s language matters. If an intervention’s specific effect is weak, that weakness should be featured, not politely escorted behind the curtains while the conclusion goes out front to smile for the cameras.

So, has credulity really infiltrated elite medicine?

In places, yes. But the story is more subtle than a simple yes-or-no verdict. What infiltrates elite medicine is often not outright gullibility. It is a softer, more respectable form of overstatement. It arrives wearing terms like “adjunctive,” “patient-centered,” “holistic,” and “nonpharmacologic.” It does not say, “Science be damned.” It says, “The evidence is complicated, but the vibe is promising.” That sounds civilized. It is also how weakly supported ideas can drift into mainstream practice without ever fully proving their specific claims.

Acupuncture remains a fascinating case study because it sits right at the intersection of three truths. First, patients with chronic pain are often desperate for relief, and medicine does not always provide it. Second, rituals, expectation, and therapeutic context can genuinely influence symptom experience. Third, serious journals still have a duty to distinguish a helpful clinical ritual from a specifically validated scientific mechanism.

When they fail to do that, skepticism is not cynicism. It is quality control.

Experiences related to the topic: what this debate feels like in real life

One reason the acupuncture argument never goes away is that it feels completely different depending on where you stand. To a patient with chronic pain, the debate can seem almost insulting. If someone has spent years cycling through physical therapy, anti-inflammatory drugs, sleep disruption, medical bills, and the emotional exhaustion of hurting every day, then a few sessions of acupuncture that reduce pain even modestly can feel like a minor miracle. That patient is not conducting a seminar on trial design. That patient is trying to get through Tuesday.

From the clinician’s side, the experience can be equally complicated. Doctors treating chronic pain know that many standard therapies are imperfect. Medications can carry side effects, dependency risks, or only limited benefit. Surgery is not always appropriate. Exercise helps, but not everyone can start there. In that setting, acupuncture can look attractive because it is low risk, nonpharmacologic, and for some patients, subjectively useful. A physician may recommend it not because they believe in meridian theory, but because they know the real world is not a tidy randomized trial and pain medicine rarely offers perfect choices.

Then there is the experience of the skeptical reader, which is almost the mirror image. This reader sees a prestigious journal discuss acupuncture and immediately scans for the missing caution signs. Did the article separate benefit from mechanism? Did it explain how often sham acupuncture performs similarly? Did it clarify whether outcomes were objective or subjective? If the language feels too smooth, the skeptical reader hears alarm bells. Not because they hate patients feeling better, but because they know how easily medicine can begin laundering weak evidence through respectable institutions.

Editors and science writers experience a different tension altogether. They are often trying to describe evidence that is mixed, condition-specific, and irritatingly resistant to a neat headline. “Acupuncture may modestly help some patients in some contexts, but much of the effect may be nonspecific and the traditional theory remains weakly supported” is accurate, but it is not exactly click-happy. The temptation to simplify is enormous. That is how a cautious evidence summary can accidentally emerge sounding like an endorsement.

Patients themselves also have wildly different experiences inside acupuncture clinics. Some find the sessions calming, attentive, and more humane than rushed office visits. Others feel no benefit at all and leave wondering why they just paid to become a decorative pincushion. Some appreciate acupuncture precisely because it offers time, ritual, and focused listening, three things modern health care often rations like precious metals. That experience should not be dismissed. But it also should not be confused with proof that the specific map of acupuncture points has been scientifically confirmed.

In the end, the lived experience around this topic explains why the argument remains so heated. Pain is personal. Evidence is impersonal. Journals have to translate one into the language of the other. When they do that carelessly, both sides feel betrayed: skeptics think science has gone soft, and patients fear their relief is being mocked. The best writing on acupuncture avoids both errors. It respects suffering, respects evidence, and resists turning either one into a cartoon.

Conclusion

The enduring lesson of the acupuncture controversy is not that patients are foolish, skeptics are joyless, or journals are corrupt. It is that prestige does not eliminate the need for precision. Acupuncture may have a place as an adjunctive option for some pain conditions, especially when patients are fully informed and expectations are realistic. But if sham acupuncture often performs nearly as well as the real thing, then elite medical publications must say so clearly and repeatedly.

That is where the phrase “credulity about acupuncture infiltrates the New England Journal of Medicine” still bites. It reminds readers that scientific seriousness is not just about publishing data. It is about framing data honestly, especially when a treatment lives in the foggy borderland between ritual, placebo, physiology, and hope. Medicine owes patients compassion. Journals owe readers clarity. Ideally, both can happen without anyone pretending a needle has become a magic wand.

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