Head To Head

Should doctors recommend acupuncture for pain?

BMJ 2018; 360 doi: https://doi.org/10.1136/bmj.k970 (Published 07 March 2018) Cite this as: BMJ 2018;360:k970
  1. Mike Cummings, medical director1,
  2. Asbjørn Hróbjartsson, professor2,
  3. Edzard Ernst, emeritus professor3
  1. 1British Medical Acupuncture Society, London, UK
  2. 2Center for Evidence-based Medicine, University of Southern Denmark, Odense, Denmark
  1. 3University of Exeter, Exeter, UK
  2. Correspondence to: M Cummings mike.cummings{at}btinternet.com, Asbjørn Hróbjartsson asbjorn.hrobjartsson{at}rsyd.dk

It’s a safe alternative to drugs that is under-researched because it lacks commercial interest, writes Mike Cummings, but Asbjørn Hróbjartsson and Edzard Ernst argue there is no convincing evidence of clinical benefit and that the potential risks and health service costs are unjustified

Yes—Mike Cummings

Guidelines in most developed countries recommend acupuncture for treating pain. Indeed, in Brazil, acupuncture is recognised as a medical specialty.1 The UK is an exception, with only Scotland recommending acupuncture for chronic pain.2

In the US, acupuncture is recommended for back pain,3 but in the UK it is no longer included in the National Institute for Health and Care Excellence’s (NICE) guidelines for low back pain. The 2009 guideline on early management (CG88) was the first to recommend acupuncture, but it was removed in the controversial 2016 update.45

Acupuncture remains in the NICE guideline on headaches, and is the only treatment recommended for prophylaxis of chronic tension type headache. Curiously, this guideline calculates that the anticonvulsant topiramate is twice as good as acupuncture in preventing migraine, even though direct comparisons with drugs favour acupuncture.67

Sham acupuncture

The approach adopted by NICE compares the benefit of acupuncture over sham acupuncture, with the benefit of topiramate over a placebo, rather than directly comparing acupuncture with topiramate.

This approach assumes that sham acupuncture has no effect beyond an inert pill; however, a large meta-analysis on the differential effects of placebo treatments (in headache) shows that sham acupuncture (and sham surgery) are associated with higher response rates than oral placebos.8 So the baseline used for these comparisons is uneven. This explains why the NICE guideline on headaches recommends drugs before acupuncture in prophylaxis of migraine whereas the Cochrane review reports acupuncture is better (immediately after a course of treatment).6

The …

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