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Important study on benefits of conservative treatment in reducing opioid take-up excludes acupuncture from the abstract

The study (Kazis et al 2019) was published recently in the British Medical Journal. Researchers took US health insurance data from 2008-2013 to identify a large sample of people newly diagnosed with low back pain, who had not been taking opioids. The various initial healthcare providers for these patients could be loosely grouped into physicians or conservative therapists. Acupuncturists were included in the latter group, along with physiotherapists and chiropractors. The numbers of patients seeing each of these were 1839, 3499 and 50,041 respectively. The researchers then looked at subsequent opioid prescriptions for these patients, both early use (within 30 days of the initial back pain consultation) or long term, and mapped it to their type of healthcare provider. They calculated the odds of short- and long-term opioid use for each type of provider compared to a primary care physician (PCP) as standard.

All of the conservative treatments were associated with a much reduced likelihood of subsequent opioid use compared to a PCP. For acupuncture the reduction was 91% for short-term and 93% for long-term. The figures for physiotherapy and chiropractic were similar (though not quite as good for long-term). The conservative therapies were better in this respect than any of the physician treatments.

Being observational, retrospective data you can’t say that these associations are the same as cause and effect. There are various possible unmeasured factors that could have affected the results, for example, the conservative therapies may have been chosen preferentially by people with less severe back pain, or by those who wanted to avoid opioids. Nevertheless this is an important paper indicating that treatments such as acupuncture may be beneficial in helping with the current ‘opioid crisis’. It adds to existing acupuncture publications with a similar message in respect of opioid use with both chronic and acute pain. It can help to make the case for there being increased access to conservative therapies, especially for people who want opioids or other analgesic drugs.

The issue is not with the research and the results, as presented in the body of the paper, but with the fact that notice of the acupuncture benefits has been completely excluded from the abstract. We can only speculate as to why this has happened. Yes, the sample of acupuncturists was relatively small for such a study but the estimate of the effect was significant and of a similar accuracy to that for physiotherapy.

The omission is serious because people tend to scan abstracts in the first instance to get a rough idea of the message. They may not go on to look at the whole paper at all. In this case the abstract tells us that acupuncture was one of the treatments included but makes no mention of it in the results or the conclusions. By contrast, both physiotherapy and chiropractic are specified in each of those sections. Readers of the abstract would likely get the impression that acupuncture did not appear to have the same benefits as these other therapies.

Together with national acupuncture organizations in the US we have written to the journal to ask for an explanation and a correction.

 

Kazis et al (2019). Observational retrospective study of the association of initial healthcare provider for new-onset low back pain with early and long-term opioid use. BMJ Open 2019;9e028633. https://bmjopen.bmj.com/content/9/9/e028633

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