Cupping: “the propagation of ancient, scientifically unsound techniques that may cause more harm than benefit”

We have often discussed cupping on this blog, e.g.:

• The ‘WORST PAPER OF 2022 COMPETITION’ entry No 6: “The efficacy and safety of dry cupping in cervical spondylosis with optimization of cup application time – A randomized clinical trial”
• Cupping therapy for non-specific chronic low back pain
• Cupping for Olympic swimmers. Or: why breaking your shoulder is not necessarily good for writing a successful book
• Infant receiving cupping treatment prompts outrage

Yes, generally speaking I have been critical about cupping – not because I don’t like it (I even used the treatment as a young clinician many years ago) but because the evidence tells me to. I was glad to see that the authors of a recent article entitled “Utility of Cupping Therapy in Substance Use Disorder: A Novel Approach or a Bizarre Treatment?” offer even more outspoken words about the therapy. Here are their conclusions:

Established treatment modalities for substance use disorder and its withdrawal symptoms include pharmacotherapy and psychotherapy, but their utilization by the general population remains unsatisfactory. Taboos regarding mental health services and concerns about confidentiality are massive obstacles for patients seeking psychiatric help, and alternative forms of medicine may seem more approachable, even with the associated risks. As displayed in this case, cupping therapy is a traditional therapy with no role in treating polyaddiction and withdrawal symptoms, but it unnecessarily exposes individuals to really uncomfortable and often concealed complications such as bruising, and skin and blood infections, especially when carried out by untrained, incompetent individuals. While one can explore these options in addition to seeking professional mental health care, it is imperative to spread awareness about the roles, scientific soundness, and adverse effects of these alternative health practices. The health promotion and education sectors need reforms to educate the general population, especially the rural population in India, about the dangers of iatrogenesis caused by non-evidence-backed treatments. There needs to be an extensive advertisement of only the most effective and scientific treatment options provided by medical professionals, and the risks of overlooking them in favor of traditional cures propagated by unqualified individuals. With all the scientific advancements in the 21st century ranging from artificial intelligence in healthcare, and robotic surgeries, to extensive clinical trials for novel anti-cancer drugs, we cannot allow the propagation of ancient, scientifically unsound techniques that may cause more harm than benefit to patients.

Why, I am sure you ask yourself, are they so critical? The reason lies in the case they report in the same paper:

A 30-year-old man presented to the psychiatric outpatient department with complaints of nervousness, anxiety, a sense of impending doom, irritability, anger outbursts, headache, and reduced sleep and appetite for the last five days. The patient had a history of daily consumption of 5-10 mg of alprazolam tablets, 200-250 mg of codeine syrup, and about five packets of chewable tobacco over the last seven years; this was a pattern of polyaddiction to a benzodiazepine, opiate, and nicotine. The patient had no history of fever, confusion, or hallucinations. On eliciting the past history, the patient revealed that he went to an alternative medicine practitioner after his family persuaded him to seek help for his substance use disorder. After ceasing the consumption of all three substances for three days, he started developing the symptoms with which he presented to our hospital. He was hesitant to talk about his substance use disorder to medical professionals and concerned about confidentiality, and, hence, went to an alternative medicine practitioner whom he deemed approachable. There he was given wet cupping therapy on the head for four days, which involved the use of rubber pumps to create a suction inside the cups placed on his head. After three to five minutes, the cups were removed and small incisions were made on the cupping sites, following which a second suction caused the oozing out of blood from the incision sites on the scalp (Figure 1). But, this did not improve his symptoms, and hence, he stopped going there two days before coming to our tertiary care hospital.

Figure 1: Wet cupping therapy on the head with blood oozing from incision sites<

On examination, the patient had a pulse rate of 76 beats per minute, blood pressure of 128/78 mm Hg, and respiratory rate of 22 per minute. He was well-oriented to time, place, and person. Systemic examination of the cardiovascular system was unremarkable. He denied any other substance use. The skin over his head had distinct cupping marks but no signs of infection or active bleeding, which are some common complications after cupping therapy (Figure 2). On assessment, the patient had a Clinical Opiate Withdrawal Scale (COWS) score of 13 and a Clinical Institute Withdrawal Assessment (CIWA) scale score of 26.

Figure 2: Cupping marks on the head

Later, the patient was admitted to the psychiatric ward to manage the withdrawal symptoms, where we initiated pharmacotherapy. Tablet diazepam (20 mg/day), sodium valproate (800 mg/day), tramadol (200 mg/day), thiamine (300 mg/day), paracetamol (500 mg/day) and intravenous fluids were given to the patient. We counseled the patient regarding substance abuse, its harmful effects, and de-addiction. The patient’s symptoms started to improve, and we continued the treatment for four days and discharged him with a COWS score of 4 and a CIWA score of 2. We intended to reassess him after 14 days, but we lost him to follow-up.