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Does evidence support doctors recommending acupuncture for pain?

Some say it does; others say no convincing evidence of clinical benefit, and potential for harm

Louise Prime

Thursday, 08 March 2018

For patients who choose acupuncture to treat chronic pain and who respond well, it considerably improves their health-related quality of life – with much lower long-term risk than non-steroidal anti-inflammatory drugs (NSAIDs), according to one author of a head-to-head opinion piece* in today’s BMJ. But on the other side of the debate, two professors of evidence-based medicine argue that clinical pain trials comparing acupuncture with placebo find only a small, clinically irrelevant effect that cannot be distinguished from bias – and doctors should not recommend it for pain.

Mike Cummings, medical director of the British Medical Acupuncture Society (BMAS) in London, points out that most developed countries recommend acupuncture for treating pain – in Brazil it is even a recognised medical speciality – yet in the UK, Scotland alone recommends acupuncture for chronic pain. The National Institute for Health and Care Excellence (NICE) lists acupuncture as the only treatment recommended for prophylaxis of chronic tension-type headache. But although acupuncture is recommended in the US for low back pain, and NICE originally recommended it in its 2009 guideline on early management, NICE removed it during its ‘controversial 2016 update’.

He argues that a large and robust dataset for acupuncture in chronic pain, from a review of data from 20,827 patients, shows moderate benefit for acupuncture compared with usual care, but smaller effects compared with sham acupuncture; and it also shows that 85% of the effect of acupuncture is maintained at one year.

He questions whether money might be the real reason for the decision not to include acupuncture in pain guidelines because, as he acknowledges, “[It] seems to incur more staffing and infrastructure costs than drug-based interventions, and in an era of budget restriction, cutting services is a popular short-term fix.” Furthermore, he notes, there is no commercial sector interest in acupuncture so it does not benefit from the lobbying seen for patented drugs and devices.

He summarises: “The pragmatic view sees acupuncture as a relatively safe and moderately effective intervention for a wide range of common chronic pain conditions… It may be especially useful for chronic musculoskeletal pain and osteoarthritis in elderly patients, who are at particularly high risk from adverse drug reactions.”

But Asbjørn Hróbjartsson, professor of evidence-based medicine at the University of Southern Denmark and Edzard Ernst, emeritus professor at the University of Exeter, respond simply: “Doctors should not recommend acupuncture for pain because there is insufficient evidence that it is clinically worthwhile.”

They explain that overviews of clinical pain trials comparing acupuncture with placebo have found only a small, clinically irrelevant effect that cannot be distinguished from bias. Furthermore, they add, not a single Cochrane review of acupuncture for pain reported a clinically important effect beyond placebo; although, they acknowledge, “the reviews on back pain, migraine, and tension type headache considered acupuncture a possible treatment option based mostly on trials with non-blinded patients, but effects beyond placebo were ‘small’, [...] [and] even that effect may be due to bias rather than acupuncture”.

Additionally, they note that although often regarded as harmless, acupuncture needling has been reported to cause pain, haemorrhages, infection, pneumothorax, and even death.

They conclude: “After decades of research and hundreds of acupuncture pain trials, including thousands of patients, we still have no clear mechanism of action, insufficient evidence for clinically worthwhile benefit, and possible harms. Therefore, doctors should not recommend acupuncture for pain.”

*Cummings M, Hróbjartsson A, Ernst E. Head to Head: Should doctors recommend acupuncture for pain? BMJ 2018; 360: k970 doi: 10.1136/bmj.k970.

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