Acupuncture: Calling the Defense

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An article in the British Medical Journal asked whether doctors should recommend acupuncture for pain and then presented the argument for both sides. However, the argument against acupuncture suffered from three important flaws


The case against recommending acupuncture based much of its argument on the claim that "not one of 12 Cochrane reviews of acupuncture for pain reported a clinically important effect beyond placebo. . . ." However, in at least several of the cases, the authors misrepresent and overstate the negative conclusion. 

The 2005 review of low back pain to which they refer, for example, did say that "The data do not allow firm conclusions about the effectiveness of acupuncture for acute low-back pain." But, it also says that for "chronic low-back pain, results show that acupuncture is more effective for pain relief than no treatment or sham treatment" and that "for chronic low-back pain, acupuncture is more effective for improving function than no treatment." Finally, the review concludes that "When acupuncture is added to other conventional therapies, it relieves pain and improves function better than the conventional therapies alone."

As for the 2015 Cochrane review of acupuncture for cancer pain, although the studies were all small, several were positive. One was too small to find a difference. But one found acupuncture to reduce cancer pain compared to sham acupuncture. Another found it was better than sham acupuncture for the pain of pancreatic cancer. Importantly, a third found it was as effective as pain-killing medications while a fourth found it was better than medication (doi:10.1002/14651858.CD007753.pub3).

The Cochrane review of lateral elbow pain, or tennis elbow, was not entirely negative. Based on two randomized controlled studies it found that acupuncture is of short term benefit for pain for lateral elbow pain. One found that acupuncture results in relief of pain for significantly longer than placebo and is more likely to result in a 50% or greater reduction in pain after 1 treatment , and the other found acupuncture to be more likely than placebo to result in overall improvement in the short term (doi:10.1002/14651858.CD003527).

As for the 2011 review of endometriosis, only one study was included in this review, but it found that it was effective (doi:10.1002/14651858.CD007864.pub2).

The authors of the "No" side in the BMJ article also give insufficient weight to updates to the Cochrane reviews that take into account newer, better designed studies. The 2006 review of acupuncture and neck pain was updated in 2016 (doi:10.1002/14651858.CD004870.pub4). This updated Cochrane review looked at twenty-seven randomized studies of acupuncture and neck pain. The meta-analysis significantly favoured acupuncture. The researchers said that acupuncture is cost effective and safe treatment with only minor adverse effects. The researchers said that, since their 2006 review, the quality of randomized controlled trials has improved. They concluded that "Moderate-quality evidence suggests that acupuncture relieves pain better than sham acupuncture" and that "Moderate-quality evidence also indicates that acupuncture is more effective than inactive treatment for relieving pain."

In 2016, an update was published of the 2009 review of acupuncture for episodic or chronic tension-type headaches (doi:10.1002/14651858.CD007587.pub2). The updated Cochrane review looked at twelve controlled studies. When acupuncture was compared to "routine care or treatment," 48% of the acupuncture group had at least a 50% reduction in headache frequency versus only 19% in the conventional care group. When acupuncture was compared to sham, or placebo, acupuncture, 51% had at least a 50% reduction in headaches versus 43% in the placebo group. Acupuncture was very safe. The studies were controlled but not all were blinded. The quality of the studies was, otherwise, high. The researchers concluded that "The available results suggest that acupuncture is effective for treating frequent episodic or chronic tension-type headaches.

The 2009 review of acupuncture and migraine was also updated in 2016 (doi:10.1002/14651858.CD001218.pub3O). The updated Cochrane review looked at twenty-two moderate quality, controlled studies of acupuncture on migraine. Acupuncture was moderately better than no acupuncture treatment: headache frequency was cut by at least half in 41% of people versus 17% in the no treatment group. Acupuncture also had a significant benefit over placebo sham acupuncture. Most importantly, acupuncture reduced migraine frequency significantly more than drugs after treatment. Acupuncture maintained its superiority after follow up, though the difference was no longer significant: after three months migraine frequency was reduced by at least half in 57% of the acupuncture group and 46% of the drug group; after six months the numbers were 59% in the acupuncture group and 54% in the drug group. Acupuncture was much safer than the prophylactic drugs. The authors concluded that "adding acupuncture to symptomatic treatment of attacks reduces the frequency of headaches" and, understatedly, that "acupuncture may be at least similarly effective as treatment with prophylactic drugs."


The last couple of years have seen a dramatic number of positive acupuncture pain studies. Acupuncture has been shown to work better, faster and more safely than IV morphine in ER patients suffering from acute moderate to severe pain: morphine worked 78% of the time, but acupuncture worked a significantly better 92% of the time.

A meta-analysis of nine controlled studies demonstrated acupuncture's superiority for chronic back pain: an impressive feat, since in four of the nine studies people had not responded previously to conventional therapy. It's superior for neck pain too. People who had suffered from neck pain for six years had significantly more improvement when they received acupuncture than when they received standard therapy of physical therapy and medication.

A just published review of fifteen controlled studies of acupuncture for carpal tunnel syndrome and neuropathies found that acupuncture is beneficial for neuropathies caused by diabetes, Bell's palsy and carpal tunnel syndrome. They also concluded that it is probably effective for HIV-related neuropathy.

Another just published study treated people with irritable bowel syndrome (IBS) with either 50mg of pinaverium bromide three times a day or acupuncture. Acupuncture helped more, and it helped more people: 86.7% versus 64.3%.

Acupuncture has also proven to be effective for labour pain in a review of three studies.

A massive 2017 meta-analysis published in the Journal of Pain looked at thirty-nine well controlled studies of acupuncture and pain from nonspecific musculoskeletal pain, osteoarthritis, chronic headache, or shoulder pain. Acupuncture was significantly better than sham acupuncture or no acupuncture for all four pain conditions. The benefits of acupuncture persisted over time. The researchers concluded that "Acupuncture is effective for the treatment of chronic musculoskeletal, headache, and osteoarthritis pain. Treatment effects of acupuncture persist over time and cannot be explained solely in terms of placebo effects. Referral for a course of acupuncture treatment is a reasonable option for a patient with chronic pain."


The third flaw is to be found in the context. The claim is that doctors shouldn't recommend acupuncture because it doesn't work. But, that is a joke: the alternative is for doctors to recommend pharmaceutical pain-killers presumably because they do work. But they don't. The powerful opioids work worse than the over-the-counter pain-killers acetaminophen (Tylenol) and NSAIDs (Aspirin), which is impressive, since the over-the-counter pain-killers don't work at all. What's worse is that they not only don't work, unlike acupuncture, they come with serious risks. And, not minor risks, but serious ones like gastrointestinal bleeding; risk of major coronary events, heart attack, stroke and death in the first year after a heart attack; acute liver failure; hearing loss; and emotional problems and ADHD in children of pregnant mothers who used them.

These three important flaws in the "No" side all need to be weighed into the discussion of whether doctors should recommend acupuncture for pain. The meta-analysis of acupuncture and pain finishes with the line "Referral for a course of acupuncture treatment is a reasonable option for a patient with chronic pain."

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