Editorials

The safety of acupuncture

Acupuncture is safe in the hands of competent practitioners

Papers pp 485, 486

For many patients attracted to complementary medicine its safety has been one of its principal appeals. Complementary methods, including acupuncture, are seen as less invasive, more natural, and less liable to adverse effects than more orthodox forms of treatment. Critics of complementary medicine have, however, often castigated it as being dangerous, sometimes in the same breath as ridiculing complementary methods for their lack of effectiveness and scientific support. For many years, certainly until the mid-1980s, these debates were little more than exchanges of usually entrenched and unwavering opinion on either side.¹ Now we begin to have some evidence.

The early literature on the safety of acupuncture consisted entirely of case reports. Rampes and James summarised all case reports between 1966 and 1993, finding 395 instances of complications.² Many were minor, such as bruising or fainting, but 216 were serious, including several cases of pneumothorax and injury to the spinal cord. Only one death due to acupuncture was reported, in which a needle penetrated the pericardium. As the acupuncture was self administered, however, this perhaps falls outside the usual definition of adverse events, straying into the territory of domestic injury or deliberate self harm. In 1995 a survey in Norway found that 12% of doctors and 31% of acupuncturists had encountered adverse effects of acupuncture in their practice, including pneumothorax, nerve injury, infections, nausea and vomiting, and fainting.³ However, there was little indication of the period over which events were reported or the frequency with which complications occurred. More recently further cases of potentially life threatening complications have been reported.⁴

Important though such case reports and informal surveys are in flagging up problems, they are limited by the absence of denominator information. Assessing the degree of risk requires knowledge of both frequency and severity of the hazard.

Complications are rare and transient
Two reports in this week's issue are the first to systematically examine both the rate and nature of adverse effects of acupuncture (pp 485, 486). ^{5 6} Both suggest that the rate of complications is remarkably low and that most complications are transient, lasting two weeks at most. In total the two reports cover over 66 000 treatments given by doctors, physiotherapists, and traditional acupuncturists, with little obvious difference in either the type or rate of complications between the different groups.

Evidence of benefit is rare too
The conclusion that acupuncture is a very safe intervention in the hands of a competent practitioner seems justified on the evidence available. Certainly the dangers of many orthodox procedures are greater, though no easy comparisons can be made. The considerable risks of hospital treatment are becoming apparent,⁷ but the nature of the conditions treated, the interventions themselves, and the settings are different. A better comparison might be primary care, but the risks of adverse effects in this setting are largely unknown. Rates of adverse drug reactions or prescribing errors in primary care have varied from 0.5% to 6% at community pharmacies.⁸ While the risks of acupuncture cannot be discounted, it certainly seems, in skilled hands, one of the safer forms of medical intervention.

Clinical Risk Unit, Department of Psychology, University College London, London WC1E 6BT (c.vincent{at}ucl.ac.uk)