Acupuncture's Increasing Credibility in Research and Clinical Settings

To Contact Ms. Jamie Starkey

Jamie Starkey, LAc

Traditional Chinese Medicine Group

Center for Integrative & Lifestyle Medicine, Cleveland Clinic's Wellness Institute

Cleveland, Ohio

E-mail: starkej@ccf.org

Jamie Starkey, LAc, an acupuncturist for more than 10 years, brings a wealth of clinical and academic knowledge to her patient practice at the Center for Integrative & Lifestyle Medicine at Cleveland Clinic's Wellness Institute in Cleveland, Ohio. Informed by her upbringing, global training, and rigorous studying of the evidence, Ms. Starkey shares her approach when working with patients, the importance of communication, and the facts behind acupuncture's increasing credibility as a treatment modality.

Q: Tell us about how you first became interested in acupuncture and about your extensive training.

Jamie Starkey, LAc: My mother is Korean, and I was raised with Eastern medicine. While growing up, whenever I was sick, my mother would boil a tea for me and give me herbs. Food was always used as medicine in my household, and it did not occur to me until later in life that other families did not necessarily live the way we did. When I was 14 years of age, my family took a trip to Seoul, Korea. While we were there, my mother experienced severe neck and shoulder pain, and my aunt took her to an acupuncture clinic. When we arrived at the clinic, I realized that the acupuncturist was blind. I had never seen acupuncture before, and the fact that he was a blind clinician and was palpating my mom and inserting needles into specific areas amazed me—and she got better.

My plan through high school and undergraduate school was to attend Western medical school. However, during undergraduate school, I realized that Eastern medicine was more of my calling. This was challenging because, at that time, nobody was practicing integrative medicine in a hospital setting, and they certainly were not practicing Eastern medicine. I took a risk by going into Eastern medicine because I was not sure if I was going to be employed. This was a big concern for my mother as well. Now that she sees me employed at Cleveland Clinic, she is not so concerned.

Thankfully, I have no regrets about taking the route I chose. I have an undergraduate degree in biology. While fulfilling my Eastern medical training, I was also working at Cleveland Clinic in cardiovascular research, which allowed me to gain critical insight into hospital-based research and clinical practice. I attended school in the United States, but then studied further overseas in Beijing, China. It was there that I fully appreciated the scope of Eastern medicine. In China, we would see close to 200 patients a day, and it was nonstop and grueling. It was a humbling experience to see Eastern medicine being used to that capacity, and this experience gave me the confidence to return to the United States with a new perspective about what this type of medicine could really do for patients. I was able to take that experience and promote Eastern medicine at Cleveland Clinic, along with having a very clear understanding of how Western medicine thinks and works, and the need for supportive research evidence.

Q: How do your patients react to the perspective of Eastern medicine?

Ms. Starkey: One of the great challenges is translating Eastern medicine concepts into Western medicine understanding. I have to stay on top of the latest and highest-quality research that is available and promote acupuncture using that information. This is what makes the difference in terms of making headway and credibility in the hospital setting.

When talking with patients, clinicians have to know the level of patients' understanding. Because I have a hospital-based practice, I tend to see a significantly higher amount of Western-trained clinicians as patients and tend to explain things more technically to them. Otherwise, generally and using layman's terms, I try to explain how acupuncture works in terms of both Eastern and Western concepts. For example, if I am seeing a patient for pain, I simply say that acupuncture helps first to decrease inflammation and second to promote a pain-relieving effect in the body by manipulating the nervous system to stimulate the release of endorphins. I explain that it is similar to receiving a steroid injection and taking pain medication, except that I insert needles to manipulate the body into having a pain-relieving and anti-inflammatory effect on its own.

Eastern medicine is this beautiful, abstract form of medicine, but people with no prior knowledge of Traditional Chinese Medicine (TCM) often get “lost” in the explanation. Therefore, I try to keep the Eastern explanation simple and easily understood, addressing qi and energy flow in our bodies and the various patterns and theory by which acupuncturists are guided. I also talk with patients about steps they can take from a lifestyle and behavior perspective to mitigate the effects of what their body is exhibiting in that moment. I want patients to be empowered, being able to take actions on their own that will help.

Q: From your clinical observation and according to the literature, which medical conditions seem to be the most amenable to responding to acupuncture?

Ms. Starkey: The primary complaint of most of my patients is chronic pain. During the past several years, with the opiate overuse epidemic, we have had a number of federal organizations specifically promote acupuncture's use in chronic pain. Recently, the Joint Commission stated that hospitals should provide non-pharmacologic treatment options for pain, and they cite acupuncture. The Food and Drug Administration came out with a recent blueprint for chronic low-back pain and also specifically cited acupuncture. There was also a group of 37 attorney generals across the nation that rallied together in a letter urging insurance companies to look at widening the coverage of non-pharmacologic modalities for chronic pain control, again citing acupuncture. All of this activity on a national level is quite timely because acupuncture is so beneficial in terms of addressing chronic pain. There are not only a plethora of studies in support, but we are also beginning to understand the mechanism by which acupuncture works to achieve an analgesic effect.

There is now also much more information about cost-effectiveness. With all of this evidence, one can take that information and talk to the insurance companies about more coverage across the board. In the state of Ohio, Medicaid covers acupuncture for low-back pain and migraines. This is huge progress because from my perspective, that opens the door for patient accessibility. As this modality was once cost prohibitive for many people, changes like this allow more people access to this treatment.

Pain, especially low-back pain, makes up a good bulk of my patient base. However, I also see patients for many other complaints, such as hot flashes, fertility, seasonal allergies, as well as oncology patients suffering with side effects due to chemotherapy and radiation, and also people with irritable bowel syndrome and inflammatory bowel disease (IBD). There are several positive gastrointestinal (GI) studies promoting acupuncture's effectiveness in increasing GI transit time in functional constipation patients, decreasing anal pain, and decreasing symptoms of Crohn's disease using both acupuncture and moxibustion. Internally, here at Cleveland Clinic, we have been asked to collaborate in research projects for heart failure, IBD, and Parkinson's disease, to name a few.

One of the first acknowledged indications for acupuncture was chemotherapy-related nausea and vomiting, when the National Institutes of Health came out with their consensus statement in 1997. We have come a long way from that time in terms of large organizations and scientists acknowledging that acupuncture can be helpful for a range of medical conditions. We have had a decade or more of strong, published research studies, so the data are available.

Of course, it is at the physicians' discretion whether they prefer to refer their patients for acupuncture. Educating physicians, medical students, and residents is essential. Fortunately, the trend has really shifted in the past decade in terms of acceptance of integrative medicine.

Q: What are some key things that you have learned about acupuncture as a complementary therapy when treating patients?

Ms. Starkey: Acupuncture is a powerful modality to treat patients as a stand-alone treatment or when integrated into a multidisciplinary approach to care. It is always rewarding when you have your patients report positive outcomes. However, it is often the challenging patients who stick in my mind and teach me lessons.

All too often, by the time patients comes to see me, they have already seen a host of other specialists and tried various modalities. I do not want patients to have a sense of false hope that acupuncture is going to be the cure-all. Sometimes it is, and sometimes it is not. So, I make sure that the lines of communication are crystal clear from start to finish and throughout the entire treatment program. What I know for certain is I do not have all the answers for every patient, and I work hard to keep an open line of communication with each patient with regard to levels of expectations. Having honest conversations with patients goes a long way in terms of their healing journey.

Q: What are a couple of recent studies regarding the benefits or use of acupuncture that have impacted the field?

Ms. Starkey: There was a large meta-analysis by Vickers et al. looking at acupuncture versus sham versus no-acupuncture control for chronic pain, and the study found that acupuncture was superior to both. ¹ When that meta-analysis was published, I remember the local and national headlines reported, “Acupuncture is not placebo!” This was the first time in my professional career where my colleagues in conventional medicine appeared to have authentic interest in the findings. I often refer to this study when clinicians ask me, “Well, is acupuncture a placebo effect? Does it really work?”

There was another study published about a year ago that was conducted in an emergency room setting. This study really struck me because I had just returned from Taiwan for professional reasons and had the privilege of touring several of the hospitals there. In one of the hospitals, they now incorporate an acupuncture physician in their emergency room. Patients come in, they are assessed, and then they are triaged to the acupuncturist when appropriate. Acupuncture is specifically used for pain in that setting. One does not necessarily have to give patients medication, and their pain can be managed with acupuncture. When I returned to the United States, I thought, “I wonder if this would be something we could start exploring here locally.” That is when I came across this study, which compared acupuncture versus intravenous (i.v.) morphine in the management of acute pain in the emergency room. ² This study really impacted me because, number one, it is acute pain as opposed to chronic pain, and most acupuncture studies look at chronic pain. Second, acupuncture was being used in the emergency room setting, which I felt was very novel, especially in light of our current opiate epidemic. The study looked at three parameters: reduction in pain, pain resolution time, and side effects. The study concluded that acupuncture was better than i.v. morphine in all three of those areas.

Q: What do you hope to see in terms of future acupuncture research?

Ms. Starkey: Continuing to explore the scope of conditions for which acupuncture may benefit patients. We have covered pain very well, but pushing the boundaries even further in the realm of women's health is important, for example. There are a lot of mixed studies relating to results for menopausal symptoms and infertility. So, filling in the gaps for various conditions and seeing stronger evidence-based studies, and then also looking at more cost-effective studies will be helpful. One of the biggest challenges for many patients is their insurance companies will not pay for acupuncture services. However, if we could see more cost-effective studies, especially here in the United States, that will sway more insurance companies to cover acupuncture. I think that is absolutely critical.

Q: When should clinicians think about referring their patients for acupuncture?

Ms. Starkey: We encourage our physicians at Cleveland Clinic to refer patients who are battling conditions such as chronic pain, migraine/tension headaches, menopausal symptoms, stress management, seasonal allergies, as well as oncology patients struggling with side effects of chemotherapy and radiation (peripheral neuropathy, xerostomia, fatigue, pain, nausea/vomiting), women with morning sickness, and people with constipation. Because there are specific points in acupuncture that have the ability to engage in the relaxation/parasympathetic response, clinicians should also think about referring patients who are dealing with issues that are inflamed by high levels of stress. Acupuncture should also be considered for patients that present with a complexity of symptoms, as it is typical for patients to notice improvement in not only primary complaints, but also secondary and tertiary issues.

The average length and duration of acupuncture treatments varies. A first visit appointment is usually the longest and on average is about 60–90 minutes, which includes a thorough intake, TCM diagnosis, and development of a treatment plan, including acupuncture dosage. We talk about expectations, risks, and benefits. We have each patient sign a formal informed consent, and then we give the treatment. Follow-up visits are shorter and may be anywhere from 45 to 60 minutes. We also offer a community-style acupuncture treatment here at the hospital, where patients are being treated in a group setting. Patients must have their initial visit in a private appointment, and for patients who qualify for the group/community-style acupuncture, they often have wonderful clinical outcomes. We also integrate acupuncture into our shared medical appointments here at Cleveland Clinic. We practice auricular style acupuncture in our chronic pain shared medical appointment. While the needles are inserted, there is a hypnotherapist that goes through a guided imagery while the patients are reclined. We also integrate acupuncture into an addiction shared medical appointment.

Depending on the condition, a patient will have five to eight weeks of consecutive treatments on average. Once the patient reaches therapeutic effect, we start to taper their visits, and they come in every two to three weeks. Eventually, they come in as needed.

Q: Do you have any final thoughts or words of advice for clinicians?

Ms. Starkey: The field has come so far in the past 10 years. I have literally seen a significant transformation in the clinical setting in how other physicians view acupuncture as a viable treatment modality. I have seen changes in how the media represents acupuncture, and, of course, there are always going to be the naysayers and those people that want to claim acupuncture is placebo. The amount of referrals we receive internally within the Cleveland Clinic system is night and day from where it was 10 years ago. Initially, it was a grass-roots effort, and we spoke to whoever would listen. We had open houses, and we would invite patients to come in if they were interested in hearing our lectures. We would do demonstrations, and then eventually we got invited to speak during lunch-and-learns. Ultimately, we were invited to speak at grand rounds.

It has taken a lot of time, hard work, and dedication to arrive at the place we are now. However, doing grass-roots efforts within our own hospital system in conjunction with the amazing research that is being done nationally and internationally has created a symphony of solid work that is coming together, propelling acupuncture into the forefront of acceptance as a true medical modality. As long as we stay true to the medicine, and continue to highlight the strong clinical evidence in a way that is palatable for people to understand, then I believe that our trajectory is only going to go higher in the future. We have nowhere to go but up.▪