Intended for healthcare professionals

Rapid response to:

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

Rapid Response:

Re: Should doctors recommend acupuncture for pain? Well, what would you recommend instead?

What’s notable about this discussion is a total lack of reference to the other available treatment options for pain that doctors decide amongst and how acupuncture compares in terms of efficacy, effectiveness, safety and cost-effectiveness. Surely this is the only reasonable starting point for any intelligent discussion about how healthcare resources best be utilized.

Continuing to discuss acupuncture in an artificial vacuum, as Ernst and Hrobjartsson have done, there are a few things to note. First, the small effect size of acupuncture over sham needling for pain both demonstrates specific effects of acupuncture and simultaneously, is a completely irrelevant comparison to determine ‘clinical effects.’[1] Doctors and patients are not choosing between acupuncture and sham acupuncture needling control; they are choosing between acupuncture, paracetomol, NSAIDs, opioids, surgery, off-label, poorly tolerated, experimental medication in the case of migraines and fibromyalgia, and physiotherapy, all of which are limited in their evidence for treating pain. Sham controlled acupuncture trials merely assess two different types of acupuncture needling. Both are often superior to conventional care in terms of pain reduction and improved quality of life, with the highest-quality evidence demonstrating a statistically significant benefit of acupuncture over sham needling.[2]

If we look at sham controlled studies of orthopedic surgery, we find no difference between real surgery and fake surgery at all.[3] Clearly surgery and acupuncture have similar methodological challenges to being studied using the double-blind RCT design held as the gold-standard for pharmaceuticals. If lack of practitioner blinding is such a powerful force, this should have a much stronger effect in the case of surgery trials and yet surgery fails to demonstrate efficacy. It seems odd to argue against something with at least small specific effects and large non-specific effects (in other words, large proven clinical effects in helping patients reduce their pain) when one utilized alternative lacks evidence of efficacy and is invasive and expensive to boot.

If the authors’ reading of the acupuncture mechanism literature stops at the gate control theory, I’m confused as to why they feel qualified to comment as subject experts. Specific mechanisms for acupuncture in pain control are well-documented, including peripheral effects through purinergic signalling and nitric oxide, spinal reflexes, modulation of endogenous analgesic biochemicals, improved functional connectivity in the brain, modulation of parasympathetic activity and modulation of inflammatory signaling.[4]

Of course, the ability to articulate how a treatment works has zero relevance on clinical effectiveness. On the other hand, a recent review in this journal on the harms of paracetamol notes that the ‘mechanism of paracetamol’s analgesic action remains largely unknown.’ [5]

This comes after another recent review of paracetamol for spinal pain and osteoarthritis, also published in this journal, that finds that “paracetamol is ineffective in the treatment of low back pain and provides minimal short term benefit for people with osteoarthritis.”[6] In short, paracetamol is widely prescribed, increases the risk heart attack, stroke, kidney damage, GI bleeding and death, and we don’t know how it works which is moot because it doesn’t work anyway. As such, arguing against acupuncture, which has greater demonstrated efficacy and safety, is not an evidence-based perspective.

Another mainstay of pain treatment in the NHS are NSAIDs. These drugs suffer from a paucity of long-term studies but are frequently prescribed indefinitely, despite serious risks. A recent review looking at over 400,000 patients, also published in this journal, found that “All NSAIDs, including naproxen, were found to be associated with an increased risk of acute myocardial infarction” when taken for as little as one week.[7] A now out-dated and absurdly conservative estimate shows that the adverse effects of NSAIDs costs the NHS a median estimate of £251 million pounds a year[8].

Of course, the harms caused by NSAID and paracetamol pale in comparison to those of opioids, which are addictive, frequently debilitating and often lethal (in the UK, deaths related to prescription opioids doubled between 2005 and 2009[9]), which is why until a successful albeit illegal marketing campaign by their manufacturer in the 1990’s, oral opioids were only available as end-of life pain management for terminal cancer patients. As such, it’s interesting to note that the only study ever performed on long-term effectiveness of opioids for pain-relief found that those taking opioids were actually in more pain than controls.[10] Recommending against acupuncture to treat pain directly increases the usage of these dangerous and ineffective drugs.

Compared to physiotherapy, acupuncture has a much stronger evidence base. As one point of reference, there are over 10,000 trials on Cochrane’s Central Register for acupuncture compared to under 7,000 for physio. With this in mind, it’s interesting to note that physios frequently add acupuncture to their practice (the UK’s Acupuncture Association of Chartered Physiotherapists boasts over 6,000 members), often after very minimal training, contrary to World Health Organisation safety recommendations. It’s difficult to reconcile why physios would increasingly start using acupuncture if it didn’t work. Are you suggesting that physiotherapy is so ineffective that thousands of physios are offering a placebo to their patients instead?

Any discussion about which treatments should be recommended for pain should be based on a comparison of the benefits versus the harms of available treatments. This is self-evident. Such an approach, no matter how you slice the evidence, leaves acupuncture amongst first-line treatment options for pain, if not a clear winner. If Hrobjartsson and Ernst insist on banging the disproven placebo drum despite repeated demonstration of specific effects, clinical superiority over treatments that themselves are superior to placebo and despite the scientific community’s clear understanding of specific mechanisms of how acupuncture is able to achieve these results, then the discussion we should be having is not about the ethics of recommending placebos. Rather the discussion would need to be about the ethics of recommending treatments that fail to outperform or are inferior to a treatment that you claim is s placebo, all while exposing patients to avoidable harm. That’s the only logically consistent reading of your suggested interpretation. So let’s have a discussion about the ethics of that.

In the interest of patients and the responsible provision of healthcare resources, I sincerely invite the authors to explain: if not acupuncture for pain, then what do they recommend instead and based on what evidence? If they continue to argue against acupuncture on theoretical grounds but are not aware of options with stronger evidence of effectiveness or safety, then the medical community should continue to ignore their complaints.

References

1 Patsopoulos NA. A pragmatic view on pragmatic trials. Dialogues Clin Neurosci 2011;13:217–24.

2 Fan AY, Miller DW, Bolash B, et al. Acupuncture's Role in Solving the Opioid Epidemic: Evidence, Cost-Effectiveness, and Care Availability for Acupuncture as a Primary, Non-Pharmacologic Method for Pain Relief and Management–White Paper 2017. Journal of Integrative Medicine 2017;15:411–25. doi:10.1016/S2095-4964(17)60378-9

3 Louw A, Diener I, Fernández-de-las-Peñas C, et al. Sham Surgery in Orthopedics: A Systematic Review of the Literature. Pain Med 2017;18:736–50. doi:10.1093/pm/pnw164

4 Lund I, Lundeberg T. Mechanisms of Acupuncture. Acupuncture and Related Therapies Published Online First: 2016. doi:10.1016/j.arthe.2016.12.001

5 Roberts E, Delgado Nunes V, Buckner S, et al. Paracetamol: not as safe as we thought? A systematic literature review of observational studies. Ann Rheum Dis 2016;75:552–9. doi:10.1136/annrheumdis-2014-206914

6 Machado GC, Maher CG, Ferreira PH, et al. Efficacy and safety of paracetamol for spinal pain and osteoarthritis: systematic review and meta-analysis of randomised placebo controlled trials. BMJ 2015;350:h1225. doi:10.1136/bmj.h1225

7 Bally M, Dendukuri N, Rich B, et al. Risk of acute myocardial infarction with NSAIDs in real world use: bayesian meta-analysis of individual patient data. BMJ 2017;357:j1909–13. doi:10.1136/bmj.j1909

8 Moore RA, Phillips CJ. Cost of NSAID adverse effects to the UK National Health Service. Journal of drug assessment 1999.

9 Deyo RA, Korff Von M, Duhrkoop D. Opioids for low back pain. BMJ 2015;350:g6380. doi:10.1136/bmj.g6380

10 Krebs EE, Gravely A, Nugent S, et al. Effect of Opioid vs Nonopioid Medications on Pain-Related Function in Patients With Chronic Back Pain or Hip or Knee Osteoarthritis Pain. JAMA 2018;319:872–11. doi:10.1001/jama.2018.0899

Competing interests: I am director of Evidence Based Acupuncture

11 March 2018
Mel Hopper Koppelman
Acupuncturist, Functional Medicine practitioner and health researcher
Evidence Based Acupuncture
Rhode Island, USA