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Lessons from the American opioid crisis

Lessons from the American opioid crisis

By Mark Bovey, Research Manager

There’s been a so called ‘opioid crisis’ in the US for some years now, with tens of thousands of opioid related deaths annually. In the UK, where the mortality rates are much lower, there has not been the same recognition of a crisis but the scale of the problem has now burst into prominence with the news that more than half a million people have been on opioid pain killers for over three years. Part of the US response has been to push forward non-pharmacological options for pain control, to doctors and also health insurers. Many university hospitals and health centres have established integrative care programmes combining the best of orthodox and complementary treatments.

In the UK this sense of urgency and innovation has not yet surfaced. NICE is content to recommend more of the same. ‘Integrative’ healthcare in the UK may mean various things but incorporating complementary treatments is not one of them and NICE’s default position is to remove these therapies from the scope of any new guideline they are developing. In the US acupuncture stands as the most evidence based, immediately available choice to fulfil the calls for non-drug pain control. It is an effective, safe and cost-effective treatment for numerous types of acute and chronic pain.

The strongest evidence has emerged for chronic pain associated with the back, neck, shoulder knee and head, from a meta-analysis of 17,922 people from 29 randomised controlled trials. Acupuncture was significantly better than both usual care and sham acupuncture controls and the effects were long-lasting. In the largest single study so far, with 454,920 patients, the 8,727 treating physicians rated acupuncture as having a marked or moderate effect in more than 75% of cases. There’s also good evidence for sciatica, elbow and heel pain, dysmenorrhoea and various other painful conditions. Acupuncture was found to be as effective as exercise (recommended by NICE) and other non-pharmacological interventions for knee osteoarthritis; also as good as drugs for arthritis, low back pain (LBP), migraine and a host of other illnesses. It can even outperform morphine for A&E patients with acute pain. Moreover, unlike many drugs, certainly opioids, it is safe, as shown in large surveys of usual practice, clinical trials, literature reviews; even in hospital intensive care and cancer care. Serious adverse events are very rare with properly trained practitioners.

The third leg of the evidence base is cost-effectiveness. In a systematic review of eight economic studies of acupuncture for chronic pain it was cost-effective according to NICE criteria. Conditions with evidence of cost-effectiveness: allergic rhinitis, LBP, ambulatory anaesthesia, migraine, neck pain, depression, osteoarthritis, dysmenorrhoea, post-operative nausea and vomiting, headache. It may even be cost saving for the NHS, especially for group acupuncture, and if expensive items like surgery can be deferred.

In line with this evidence the American College of Physicians in 2017 recommended acupuncture both for acute and chronic back pain. By contrast NICE, in 2016, removed their previous endorsement of acupuncture for LBP, despite the improved evidence and in the face of considerable opposition. Currently it finds itself embroiled in similar arguments with its depression guideline, backtracking in the face of opposition (psychotherapy and counselling organisations) that has more clout than acupuncture. NICE does endorse acupuncture for headache and migraine. Its Scottish equivalent (SIGN) recommends acupuncture more generally for chronic pain, including LBP.

In addition to its standalone merits when treating people with pain it works well alongside medication. Adjunctive acupuncture can decrease the dose of opiates needed across a wide range of minor and major surgery, improves post-operative recovery and reduces the risk of subsequent opioid dependence. It can also play a part for those addicted to opiates, decreasing their substance use and improving quality of life.

In the US acupuncture is recommended by the Food and Drug Administration (FDA) and the National Academies of Sciences, Engineering and Medicine (NASEM) as a first line therapy for coping with the opioid crisis. In the UK there have been encouraging noises from some experts but no official support for acupuncture or other unconventional treatment options. If your opioids are not working, or the side effects are unpleasant, what do you put in their place? The BAcC calls on NICE to reconsider its current stance and recommend acupuncture for pain treatment.

Note that acupuncture in the UK is primarily located in private practice. GPs can refer patient to members of the British Acupuncture Council (BAcC) under GMC guidelines, as the BAcC is registered with the Professional Standards Authority. For the most part, though, people refer themselves directly. If you are taking opioids, or other medication, always speak to your doctor before considering any change to the dose. Acupuncture itself is non-addictive.

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