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EDITORIALS: Charles Vincent The safety of acupuncture BMJ 2001; 323: 467-468 [Full text]

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cost-effectiveness counts

Regina Stroebele   (3 September 2001)

Harm comes in many forms.

Tim Wilson   (3 September 2001)

Attributable Risk a better concept than Adverse Effect

James K Rotchford   (16 September 2001)

cost-effectiveness counts 3 September 2001
Regina Stroebele, so-called GP in Germany Send response to journal: Re: cost-effectiveness counts	My personal conclusions: 1. Acupuncture does not need a physician`s education. 2. Acupuncture is safe, but expensive. 3. There is a need to save money and the healthiness of poor people in Public Health Systems. 4. Acupuncture should not be paid by PHS as a physician`s task, but like other physiotherapies. And these therapies only in case there is no cheaper treatment with comparable safety and efficacy.
Harm comes in many forms. 3 September 2001
Tim Wilson, Director, St Paul RCGP Quality Unit Mill Stream Surgery, Benson Send response to journal: Re: Harm comes in many forms.	Sir, Vincent in his editorial [1] was right to point out that the two studies on the safety of acupuncture are reassuring.[2,3] He also pointed out that considering safety alone is unhelpful, a risk: benefit ratio should be considered. However, harm comes not only from adverse events. Another area of concern with "alternative" practitioners is the lack of communication with "conventional" carers, and in particular primary care. If one core element of primary care is co-ordination of care [4] then poor communication between complimentary practitioner and primary care can only serve the patient poorly. Indeed, harm may occur. Without full knowledge of the patient, their condition and medications inadvisable treatments might be advocated. Therefore there needs to be a clear link between "alternative" or, better still, complementary practitioners and the patients primary care provider. To create a linkage between primary care provider and complementary therapist does require a different approach. In our own practice we have forged strong links with a chiropractic doctor (in the past, placing a fund holding contract with one), offered accommodation to an acupuncturist and have held evening meetings with complimentary therapists to discuss the merits of their treatments. Two partners in the practice are trained in the basics of complementary therapies (acupuncture and homoeopathy). All this adds up to an open relationship between patient, their GP and their complementary therapist. One area that we have not succeeded with is in linking with herbalists. This is of some concern given the possible interactions between herbal remedies and allopathic treatment [5] and the potential problem of herbal toxicity that may not be recognised for what it is [6]. Therefore safety studies of complementary therapy needs to look at broader aspects of care and, in particular, communication and organisational problems that might arise. Tim Wilson 1 Vincent C. The safety of acupuncture. BMJ 2001; 323: 467-468. 2 White A, Hayhoe S, Hart A, Ernst E. Adverse events following acupuncture: prospective survey of 32 000 consultations with doctors and physiotherapists. BMJ 2001; 323: 485-486. 3 MacPherson H, Thomas K, Walters S, Fitter M. The York acupuncture safety study: prospective survey of 34 000 treatments by traditional acupuncturists. BMJ 2001; 323: 486-487. 4 Starfield B. Primary care: balancing health needs, services and technology. Oxford: Oxford University Press, 1998. 5 Braun L. Herb-drug interaction guide. Aust Fam Physician 2001: 30(6): 581-2 6 Borins M. The dangers of using herbs. What your patients need to know. Postgrad Med 1998; 104(1): 91-5, 99-100
Attributable Risk a better concept than Adverse Effect 16 September 2001
James K Rotchford, President of Medical Acupuncture Research Foundation Port Townsend, WA USA Send response to journal: Re: Attributable Risk a better concept than Adverse Effect	Elsewhere I've written how problematic it is to define let alone quantify adverse events associated with acupuncture. http://www.medicalacupuncture.org/aama_marf/journal/Vol11_2/adverse.html I think this is echoed to some degree in this article by Vincent. He like so many others have left out an issue I think needs highlighting: if one understands the principles behind traditional forms of acupuncture, the notion of an adverse event becomes problematic. As we attempt to utilize the same terminology and methodology that has been applied to pharmaceutical and specific surgical interventions -- with acupuncture practiced in a traditional manner -- we are going to encounter problems. In Western thought, if the result is anything but its intended result, then it is an adverse event or side effect. This is the result of linear reasoning. Linear reasoning does not translate well to acupuncture based on Oriental contextual models. For example, a patient receives acupuncture for neck pain with the only immediate result a sense of deep relaxation. Our Western paradigm would equate the relaxation with an adverse event (Relaxation has been actually termed an adverse event in some reviews) However, from a contextual Oriental Medical approach, if the patient learns to relax, then over time, his neck pain may improve. So that relaxation would not be defined as an adverse event, but a salutary effect of the acupuncture. This may appear as mere semantics. Clinical implications could however, be significant. Patients may well halt treatment or be unnecessarily concerned if they develop symptoms other than those anticipated especially if we convey to patients that all unexpected/unwanted events are adverse. We can still help patients evaluate the risks associated with acupuncture by outlining the estimated attributable risk of such events. In my opinion, this meets the ethical challenge of providing informed consent. However, this is pragmatically moot; standards of practice dictate that unless the attributable risk of a serious event to a procedure is relatively high (greater than 1 in 500), one is not obliged to discuss it with the patient. For example, we do not require informed consents for drawing blood despite the possibility of fainting, bruising, and even infection except, perhaps, in those cases where the risk is high such as in a post-mastectomy patient. I believe that given the low incidence of serious adverse events associated with acupuncture, a formal informed consent is not indicated. I think if we continue to use the same terminology and methodology to evaluate acupuncture as we do pharmaceutical agents, we neither understand classically applied acupuncture or the limits of our standard Western methodologies. Also I want to comment briefly about some colleagues questioning the benefits of acupuncture. It's obvious the benefits of acupuncture are significant, now to what degree they have to do with specific needling techniques or some enhancement of the placebo effect this all needs to be worked out. I just think it is ludricous for intelligent and/or informed individuals to deny the possible significant benefits to patients who are cared for by a qualified acupuncturist. Since it is a surgical procedure I also vote to involve physicians in it's delivery.