Acupuncture: is NICE cutting off its nose to spite its face?
Whether acupuncture works is not the issue here(1). Patients in their hundreds of thousands find it to work(2). NICE certainly found it to work In terms of superiority over no acupuncture/usual care, in fact no other non-drug therapy works better(3). Perhaps even more impressive is the sham controlled evidence. Despite sham acupuncture being another active acupuncture intervention this still produced a 0.8 SD superiority on the pain VAS from plentiful high quality data. No other non-pharmacological treatment was even at the races here, and, of the seven classes of drugs evaluated, only one (NSAIDs) did better (slightly: 1.0 SD). Rightfully concerned that NSAID adverse events might be a bit much for some patients to swallow, NICE decided to pick a back-up treatment. Was this the second placed runner, the rather safe acupuncture? No, they chose opiates (0.6 SD).
No one would dispute that exercise should be a recommended option but it has no sham data (it did at the draft stage, and exercise was not superior, but this was subsequently dropped by NICE). Likewise manual and psychological therapies. This leads to the paradoxical position where NICE recommends three treatments that have worse evidence but rejects acupuncture because it doesn’t meet the sham evidence standards that the others are exempt from. There are other equally logical positions that NICE could have taken:
- Reject all these interventions, as none meet the sham comparison standard
- Omit the sham data for all, as it is equally suspect
- Recommend on the usual care data only.
There are pros and cons for all three approaches but they are all extremes. NICE’s solution in 2009 was to follow a pragmatic line where efficacy was considered but effectiveness and cost-effectiveness trumped it. Since then it has veered to the extreme, first for osteoarthritis and now back pain.
Why the change in direction? This is not a universal phenomenon: there are more than 90 positive recommendations of acupuncture for low back pain in guidelines globally(4). Nor does NICE’s approach meet universal acclaim in the UK, even amongst stakeholders with no obvious acupuncture connection: Arthritis Research UK, The Faculty of Pain Medicine, Society for Back Pain Research, Warwick Clinical Trials Unit. The main complaint from these and others is of inconsistency in approach(5). Some go further and link this to conflicts of interest and hence the perception of bias. Certainly we would argue for NICE to avoid committee members with explicitly anti-views for one of the main interventions under consideration.
The requirements of our patient populations are becoming more complex, especially in primary care. Single treatment options are becoming less viable with a need to maintain wellbeing and independence for patients and to give them genuine options in how they choose to maintain their health. There is an argument for guidelines to be broader and more encompassing rather than more specific and selective.
So finally a plea for NICE to return to a neutral position, raised above the CAM vs sceptics battle and looking to patients’ and clinicians’ best interests rather than rigid and sterile ideology. This guideline seems retrogressive rather than leading evidence based medicine(6) . There must be different and better ways of providing, processing and interpreting evidence than has been on display here. Our offer of support is still open and we would be very willing to be part of a new way forward in guideline development.
1. Braillon A. Low back pain/sciatica and acupuncture: the international bazaar. BMJ 2017;356:i6748 http://www.bmj.com/content/356/bmj.i6748/rr-1
2. Weidenhammer W, Streng A, Linde K, Hoppe A, Melchart D. Acupuncture for chronic pain within the research program of 10 German Health Insurance Funds--basic results from an observational study. Complement Ther Med. 2007;15(4):238-46.
3. Hopper Koppelman M. NICE's data showed that acupuncture was more effective than usual care and sham needling. BMJ 2017;356:i6748 http://www.bmj.com/content/356/bmj.i6748/rr-3
4. NICE guideline 59. Low back pain and sciatica in over 16s: assessment and management. Consultation on draft guideline. Stakeholder comments table. November 2016. https://www.nice.org.uk/guidance/NG59/documents/consultation-comments-an...
5. Birch S. Update of positive recommendation for the use of acupuncture treatment. Proceeding of the 4th International Symposium of Evidence Based Clinical Practice Guideline in Traditional Medicine, Daejeon, S. Korea, Oct 27, 2015
6. Greenhalgh T, Howick J, Maskrey N. Evidence based medicine: a movement in crisis? BMJ 2014;348:g3725
Competing interests: I am a professional acupuncturist and research manager for the British Acupuncture Council