Risks of acupuncture range from stray needles to pneumothorax, finds study

BMJ 2012; 345 doi: http://dx.doi.org/10.1136/bmj.e6060 (Published 7 September 2012)
Cite this as: BMJ 2012;345:e6060

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Acupuncture, chronic pain and patient centred medicine

First we would like to correct an earlier misunderstanding; Wheway (1) reports 5 pneumothoracies, only one of which was severe. With regard to severe adverse events, the rate at which they were reported was in the order of 1 in a million.

Colquhoun’s arguments are unclear and we think he fails to understand the complexity of treating long-term chronic illness in primary care, especially in chronic pain. Vickers et al demonstrate two issues very clearly in their recently published paper (2). Acupuncture is considerably more effective than standard conventional care and its effect size versus a putative placebo is exactly of the same order of magnitude as many conventional interventions for chronic pain (3,4). Zhang clearly demonstrates that by far the largest clinical response to NSAIDs for osteoarthritis is the placebo response (3,4). Acupuncture is much safer than NSAIDs, equally effective and furthermore cost effective (5). It is difficult to design placebos for physical interventions such as surgery and physiotherapy when we do not completely understand the mechanisms involved and we are unsure if a true placebo is achievable; acupuncture definitely falls into this category (6). The fact that acupuncture offers a realistic, cost-effective, safe and evidence-based intervention for chronic pain in primary care suggests that a million acupuncture sessions per annum in the NHS is an effective patient-centred and safe use of public money rather than the outrageous waste that Colquhoun implies.

Patient-centred medicine (7) undoubtedly provides effective, safe clinical benefits for patients as well as being a vocationally rewarding practice for clinicians. Allowing individuals with chronic pain to discuss and influence their choices about their medical management plans is likely to enhance any clinical response.

There are no magic bullets for the aches and pains associated with chronic pain, arthritis and old age and specific therapeutic effects are always likely to be small. Safe, cost-effective patient-centred management must be our main goal in primary care and acupuncture now offers a realistic therapeutic choice for clinicians in the community.

References
1. Wheway J, Agbabiaka TB, Ernst E. Patient safety incidents from acupuncture treatments: A review of reports to the National Patient Safety Agency. Int J Risk Saf Med 2012 Jan 1;24(3):163-9.
2. Vickers AJ, Cronin AM, Maschino AC, Lewith G, MacPherson H, Foster NE, et al. Acupuncture for Chronic Pain: Individual Patient Data Meta-analysis. Arch Intern Med 2012 Sep 10;1-10.
3. Zhang W, Robertson J, Jones AC, Dieppe PA, Doherty M.The placebo effect and its determinants in osteoarthritis: meta-analysis of randomised controlled trials. Ann Rheum Dis 2008;67:1716–1723. doi:10.1136/ard.2008.092015.
4. Zhang W, Moskowitz RW, Nuki G, Abramson S, Altman RD, Arden N et al. OARSI recommendations for the management of hip and knee osteoarthritis, Part I: Critical appraisal of existing treatment guidelines and systematic review of current research evidence. OsteoArthritis and Cartilage. 2007; 15: 981-1000.
5. Cummings M. Modellvorhaben Akupunktur _ a summary of the ART, ARC and GERAC trials. Acupunct Med 2009;27;26-30
6. Lewith G, Barlow F, Eyles C, Flower A, Hall S, Hopwood V, Walker J. The context and meaning of placebos for complementary medicine. Forschende. 2009: 16: 404-412. Doi: 10.1159/000259371.
7. Little P, Everitt H, Williamson I, Warner G, Moore M, Gould C,et al. Preferences of patients for patient centred approach to consultation in primary care: observational study BMJ 2001;322:1–7

Competing interests: None declared

George T Lewith, Professor of Health Research

Hugh MacPherson

University of Southampton, Primary Medical Care, Aldermoor Health Centre, Aldermoor Close, Southampton, SO16 5ST

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Acupuncture safety: Towards a more meaningful interpretation of case reports of safety related incidents

The news report(1) of Wheway et al’s study(2) (adverse events associated with acupuncture) neglects to specify the incidence rate with which these events occurred. Without a denominator the data is almost meaningless.(3); patients and clinicians can only make informed decisions when they know risk in the context of an estimated frequency.

Over one million sessions of acupuncture are provided each year in the NHS.(4) Therefore 1 reported pneumothorax(2) (over three years data collection), is less than one serious adverse event per million. This is consistent with a large prospective study in which over 2 million consecutive acupuncture treatments were monitored, and reported that 2 patients had a non life threatening pneumothorax.(5) Most NHS acupuncture treatments are for musculoskeletal pain(4) and the conventional option would often involve the prescription of NSAIDs. One in 1,200 people taking NSAIDS for at least two months (estimated as 2000 people per year in the UK) will die of gastrointestinal complications as a consequence.(6)

The highest level evidence on the effectiveness of acupuncture for chronic pain comes from the recently published individual patient data meta-analysis, with data from 18,000 patients giving a clear message that acupuncture not only is better than usual care, but also outperforms sham acupuncture(p<0.001).(7)

The frequency or incidence rate is the appropriate measure for adverse event reporting. Clinical decision-making requires that we balance risk, benefit and effectiveness. The evidence we have for acupuncture suggests serious adverse events are rare and the intervention is safe and effective in competent hands.(8)

Reference List

(1) Kmietowicz Z. Risks of acupuncture range from stray needles to pneumothorax, finds study. BMJ 2012;345:e6060.
(2) Wheway J, Agbabiaka TB, Ernst E. Patient safety incidents from acupuncture treatments: A review of reports to the National Patient Safety Agency. Int J Risk Saf Med 2012 Jan 1;24(3):163-9.
(3) Calman KC. Cancer: science and society and the communication of risk. BMJ 1996 Sep 28;313(7060):799-802.
(4) Hopton AK, Curnoe S, Kanaan M, MacPherson H. Acupuncture in practice: mapping the providers, the patients and the settings in a national cross-sectional survey. BMJ Open 2012 Jan 1;2(1).
(5) Witt CM, Pach D, Brinkhaus B, Wruck K, Tag B, Mank S, et al. Safety of Acupuncture: Results of a Prospective Observational Study with 229,230 Patients and Introduction of a Medical Information and Consent Form. Forsch Komplementarmed 2009;16(2):91-7.
(6) Tramer MR, Moore RA, Reynolds DJ, McQuay HJ. Quantitative estimation of rare adverse events which follow a biological progression: a new model applied to chronic NSAID use. Pain 2000;85(1-2):169-82.
(7) Vickers AJ, Cronin AM, Maschino AC, Lewith G, MacPherson H, Foster NE, et al. Acupuncture for Chronic Pain: Individual Patient Data Meta-analysis. Arch Intern Med 2012 Sep 10;1-10.
(8) Vincent C. The safety of acupuncture. BMJ 2001 Sep 1;323(7311):467-8.

Competing interests: None declared

Hugh MacPherson, health services researcher

George Lewith, University of Southampton

University of York, Department of Health Sciences, York YO10 5DD

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The truly fascinating think that I learned from the response from MacPherson & Lewith id that "Over one million sessions of acupuncture are provided each year in the NHS".

This is a mind-boggling waste of money because acupuncture does not work to any useful extent. The latest confirmation of this comes from the study by Vickers et al, which was cited by MacPherson & Lewith to reach the opposite conclusion. It hardly matters whether it is correct that acupuncture is better than sham (as concluded by Vickers et al, contrary to much other evidence that shows no difference).

What really matters is that Vickers et al showed that the difference is far too small to be of the slightest clinical interest. Did MacPherson & Lewith read only the abstract of the paper?

Competing interests: None declared

David Colquhoun, Professor

UCL, Gower Street, London WC1E 6BT

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