Friday, 08 June 2018 13:45

BAcC gives robust feedback to NICE

The new guideline on depression should have been published by now but exceptionally, NICE have come up with a second draft. Unfortunately, this draft is as bad as the first one, with no place for acupuncture.

Last time – September 2017 – only the BAcC and Hugh MacPherson from the University of York gave feedback on the acupuncture content. This time, once again we have made robust criticism of their methods, for they seem designed to disadvantage acupuncture, as was the case for both osteoarthritis and back pain. This second round of invited comments will be considered but not formally replied to, nor posted on the NICE website. We are using every possible channel available to us and will keep you updated but it’s most unlikely that NICE will change the guideline recommendations at this late stage.

We reported here in January on the new initiatives in some US states to pilot acupuncture services for Medicaid recipients, largely for chronic pain and largely prompted by the need to offer alternatives to the problematic opioid drugs. There is sound research evidence to support such a role for acupuncture (https://www.ncbi.nlm.nih.gov/pubmed/?term=acupuncture+and+opioid+and+white+paper
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In February 2018 these developments made the news on two national TV stations in the US. Here’s the link to CBS’s coverage https://www.cbsnews.com/news/opioid-crisis-doctors-turn-to-acupuncture-treatment/, which focused particularly on acupuncture use by the military. Around two-thirds of military hospitals and other treatment centres offer acupuncture, as well as the Dept of Veterans Affairs and some private health insurers. The CBS report also highlighted that there are strong sceptical voices amongst the medical scientists but, nevertheless, there seems to be more willingness to look at acupuncture as a possible mainstream option in America than in the UK.

Perhaps the opioid ‘timebomb’, as the London Evening Standard billed it, will change things here too. In their current multi-part feature the newspaper quoted both an expert doctor and an expert psychologist as recommending acupuncture (Evening Standard 16 March 2018). They had been asked what patients are meant to do instead of take opioids. These drugs not only cost the NHS many millions in direct and indirect costs they are also hopelessly ineffective for chronic pain (see for example NICE’s 2016 low back pain guideline). Acupuncture is a much better bet, both for benefits and harms, but it remains to be seen whether there is enough political will for the NHS to take it seriously.

Acupuncture is widely used by cancer patients, not least in the US, where the backlash against opioid pain killers is strongest. Some of the indications are supported by good evidence, for example nausea and vomiting from chemotherapy; in others the evidence is weaker, but acupuncture may still be as good an option as anything else, and it has minimal side effects. Recent US research has bolstered the evidence for acupuncture’s effectiveness in reducing the pain caused by hormone therapy for breast cancer. This was a fair-sized (226 women), six-week trial of acupuncture vs sham acupuncture at 11 different cancer centres. Almost twice as many in the acupuncture group achieved a clinically meaningful improvement in pain scores, and it persisted after the treatment course was finished. The results were presented at a breast cancer conference and then made it into a commentary article in the prestigious journal ‘Nature’: https://www.nature.com/articles/d41586-017-08309-y. This would appear to be all good news but a few acupuncture sceptics posted their usual complaint: it’s just a ‘theatrical placebo’. On this occasion there has been an impressive pro-acupuncture response from biomedical experts in the field. Their main points were these:

  • Acupuncture for pain relief has a sound basis in neuroscience
  • This trial was better blinded and provides stronger supporting evidence than exists for the usual non-drug treatments used in palliative care, such as cognitive behavioural therapy (CBT) or exercise. For sceptics to reject acupuncture trial results because of inadequate blinding, but accept these other therapies, indicates an inherent bias..
  • Acupuncture can be good for patients, without the potentially serious side effects of potent drugs, so it’s worth considering even if the underlying mechanisms are unclear.

In the UK, NICE was persuaded in 2016 to continue to allow complementary and alternative therapies (including acupuncture) as treatment options in supportive and palliative care (as set out originally in its 2004 guideline: https://www.nice.org.uk/guidance/csg4). Research such as that described above should strengthen the case for the NHS to improve what is currently a patchy and largely inadequate acupuncture offering.

Acupuncture is covered extensively in the US by private health insurance but state funded Medicare and Medicaid services have been slow to follow suit. Medicaid is funded jointly by the federal government and individual states, to supply health cover for people on low incomes, children, pregnant women, the elderly and those with disabilities. Now a few states are offering acupuncture as part of this cover.

Oregon (https://www.integrativepractitioner.com/whats-new/all-news/evidence-opens-medicaid-oregon-acupuncture/)
2012-13: pregnancy related conditions, migraine, tension headaches, depression and mood disorders, knee osteoarthritis, neck pain. Chemical dependency has been covered for a longer time.

Ohio (https://www.integrativepractitioner.com/whats-new/all-news/ohio-open-medicaid-acupuncture-comment-period-open-june-23/)
2017: back pain, migraine. Acupuncturists are pressing for this to be extended to other conditions.

Vermont (https://www.integrativepractitioner.com/whats-new/vermont-medicaid-acupuncture-pilot-produces-positive-results-possible-action/)
2016: Pilot project run with acupuncture for chronic pain (various conditions across the board). The results were largely positive but not compelling enough for the legislative leaders: no firm decisions have been made about subsequent cover.

Maine (https://www.integrativepractitioner.com/whats-new/all-news/maine-to-begin-national-acupuncture-detox-association-pilot-project/)
2017: Pilot project planned, using ear acupuncture for substance misuse.

This little flurry of activity has been driven by what’s popularly known as the ‘opioid crisis’. There’s a growing realisation that the increasing levels of use of opioid pain killers are unsustainable in terms of the side effects of these drugs. The biggest users are the US, hence the pressures there for policies to deal with it. You can read here (https://acupuncturenowfoundation.org/doctors/) the submission from a joint acupuncture task force in response to a US government request for public input. It summarises the research evidence supporting acupuncture as a safe and effective treatment for chronic pain. As yet there’s no federal push for acupuncture in the health insurance programmes but there is funding going into research on non-drug alternatives to opioids.

Hopefully, in time, the combination of new research findings and popular pressure will encourage more states, and indeed the federal government, to cover acupuncture for public health insurance.

The US continues to produce some surprisingly good acupuncture stories, this one from the Academy of Integrative Pain Management’s 28th Annual Meeting, written up by/for Medscape, an online magazine for all things medical. The article can be accessed here: https://www.medscape.com/viewarticle/887754?nlid=118855_1982&src=WNL_mdplsnews_171103_mscpedit_fmed&uac=5124HY&spon=34&impID=1473594&faf=1

This made news because the conference speech was delivered by a professor of anaesthesiology, an unusual source for a pro-acupuncture story. He kicked off with some sound bites: ‘I think it’s fair to say that acupuncture is here to stay. It’s going to be a permanent addition to our tool box.’ Dr Ahadian also said ‘to reach their “full potential”, clinicians need to “fully integrate” conventional medicine with alternative therapies, which includes acupuncture.’ In essence, integrative medicine in the US takes two quite different forms. In one, the doctors do the acupuncture; in the other, professional acupuncturists do it. The acupuncturists can even be part of a team of equals who collaboratively design the service and make the clinical decisions, as in this project at Harvard University (https://www.ncbi.nlm.nih.gov/pubmed/27028029}.

Setting aside what form the integration with biomedicine might take, you have to say the article is great publicity for acupuncture. First of all the author goes through the findings of the excellent Vickers’ meta-analysis for chronic pain, which provides strong evidence that acupuncture is more than just a placebo, and that it gives clinically important benefits for back pain, headache and osteoarthritis. This has been endorsed recently by the National Institute for Health Research (the NHS’s research arm), both in an online article (https://discover.dc.nihr.ac.uk/portal/article/4000746/acupuncture-shown-to-have-benefits-for-treatment-of-some-chronic-pain) and a short Facebook video (https://www.facebook.com/OfficialNIHR/videos/1680474695351290/).
Dr Ahadian then moved onto brain neurology. Various networks connect different areas of the brain with a common function, for example pain processing or managing emotional issues, and it’s been known for some years that acupuncture can help to re-set these when they go out of synch. The article refers to a recent study with patients with knee osteoarthritis. Six acupuncture treatments improved clinical scores (vs sham), which was associated with enhanced functional connectivity in brain networks involved in pain control. As we get to know more about the physiological mechanisms through which acupuncture may work there will surely be more science to underpin the benefits seen by patients in practice.

Most people would not consider acupuncture as a possible preventive measure against dementia but this is the finding from a recent Taiwanese research study. They looked at the probability of developing dementia in the years after surviving a stroke. Dementia commonly occurs after a stroke and as well as the effects of this on independent living it also makes another stroke more likely. There has been a substantial amount of research on acupuncture and dementia in China but mainly to investigate possible physiological mechanisms.

This Taiwanese study made use of the fact that very large amounts of data from their National Health Insurance programme (affecting 99% of the population) are available for research purposes. The database records include patient demographics, diagnoses, treatments and expenditures. The researchers identified 226,699 new stroke survivors aged over 50 years in the period 2000-2004. Of these, 5610 had received acupuncture. A control group was formed by selecting non-acupuncture stroke survivors, matched one to one so that their baseline characteristics were almost identical to the acupuncture users (this sort of research is called a retrospective matched cohort study). Each group was analysed up to the end of 2009, and the number of dementia cases diagnosed during that time was recorded.

The acupuncture patients had a lower incidence of newly diagnosed dementia: 26.5 vs 34.6 per 1000 person-years, a significant difference. Acupuncture also appeared to be more effective than standard physical rehabilitation, but combining both treatments was the best option, as shown in the table.

 

Treatment    Dementia incidence per 1000 person-years
No acu, no rehab   35.9
Rehab alone  34.1
Acu alone    29.8
Both acu & rehab   25.0

This benefit did not hold for the sub-group of patients with haemorrhagic stroke (bleeding from the brain, rather than the more common ischaemic type, where the blood supply gets blocked) but these only made up 8% of the total.

Imaging studies have shown that acupuncture has a stabilising effect on activity in the brain but the evidence that this leads to clinical improvement for neurological conditions like MS, Parkinson’s Disease, stroke and dementia is thin on the ground. Although it has its limitations this present study has the enormous advantages of a large sample size and relevance to the whole population. As such it is an important addition to our knowledge on the possible benefits of acupuncture for stroke and dementia.

Last month one of the top US medical journals, the Journal of the American Medical Association (JAMA), carried an article on the prevention of migraine. Although this was billed as being a summary of information about treatment options that are endorsed by the US government this didn't appear to be true, and moreover acupuncture was missing. Acupuncture is one of the very best treatments for preventing migraines, and is even recommended by NICE for use in the NHS, so we thought that it was worth writing a letter to the editor. In the event, they chose not to publish it but we reproduce it below, to give you an idea of the various arguments and to encourage others to take up their pens when they think there is a case to answer.

Questioning the medical establishment: a letter about migraine

BAcC member Beverley de Valois is well known as an expert and researcher in the use of acupuncture for cancer survivors.

She is a Research Acupuncturist at the Lynda Jackson Macmillan Centre, Mount Vernon Cancer Centre in London and also holds an honorary research position at the School of Social and Community Medicine, University of Bristol.

She has published a series of papers on the benefits of acupuncture for cancer survivors and is writing a book on acupuncture and cancer survivorship. Her PhD investigated using acupuncture to manage hormone treatment-related hot flushes experienced by women with early breast cancer. In her post-doctoral research, she turned her attention to lymphoedema and was awarded a grant by the National Institute of Health Research (NIHR). Her clinical trial in this area entails both quantitative measurement of the treatment effects and also qualitative investigation into the thoughts, feelings and experience of the participants.

It is the qualitative paper “The monkey on your shoulder”: a qualitative study of lymphoedema patients’ attitudes to and experiences of acupuncture and moxibustion that Beverley entered into the 2017 competition for the prestigious "Scientific Article Prize" put up by the International Society of Complementary Medicine Research ( ISCMR). This competition covers papers published internationally over the last two years. Qualitative research rarely makes the headlines or wins the plaudits so we applaud her for this recognition and hope that next time she can go one better: any prize money would be ploughed back into her workplace.

The paper is an open access paper and is available at http://dx.doi.org/10.1155/2016/4298420

 

The Australian Acupuncture and Chinese medicine Association (AACMA) commissioned this review to provide an up to date evidence based guide to the effectiveness of acupuncture using scientifically rigorous methods. Comprehensive acupuncture reviews have been published by the Australian (2010) and US (2013) Departments of Veterans’ Affairs in recent years and this current study built on those by adding data from 2013-16.

These are all, strictly speaking, over-reviews, where published systematic reviews of (largely) randomised controlled trials are collected together and summarised. The results thus reflect the highest level evidence available.

122 different health conditions are represented and the evidence in each of these has been assigned to one of four categories:

Evidence levelNumber of conditions
Positive effect 8
Potential positive effect 38
Unclear/insufficient 71
No evidence of effect 5

The American College of Physicians recently published a guideline entitled Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain: A Clinical Practice Guideline From the American College of Physicians

http://annals.org/aim/article/2603228/noninvasive-treatments-acute-subacute-chronic-low-back-pain-clinical-practice

How very confusing these guidelines are. No sooner does NICE change its mind and give acupuncture the thumbs down for low back pain than up pops the American College of Physicians (the largest medical speciality organisation in the USA) to endorse it. Their conclusions are in line with those of two US government agencies that reviewed the evidence in 2016 and found acupuncture to be an effective treatment for chronic back pain (Agency for Healthcare Research and Quality, Feb 2016; Nahin et al, Sept 2016). How can different guidelines, using much the same data, come up with such different answers? Well, guideline recommendations reflect not only the state of the evidence but also how this evidence is interpreted by the people producing them, and this is subject to all kinds of personal and institutional influences. Hence single guidelines cannot really be trusted: as with builders’ quotes you’d be wise to look at several different ones and get a consensus.

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