Dr. Goldman's Blog

Should doctors recommend acupuncture?

Some doctors recommend it. Others call it quackery. Dr. Brian Goldman, @NightshiftMD weighs in on an increasingly polarizing debate.
In this 2007 photo, one inch seirin acupuncture needles are used in the muscles around the spine of a patient at the Pacific College of Oriental Medicine in Chicago. (M. Spencer Green/The Associated Press)

Acupuncture has been around for more than 2,000 years. A 2017 Fraser Institute report calls it the third fastest growing complementary therapy in Canada after massage and yoga. But the ancient remedy been the subject of much recent debate. Last week, the British Medical Journal asked if doctors should recommend acupuncture to patients and got two very different answers.

Arguing in favour of acupuncture was Dr. Mike Cummings, Medical Director of the British Medical Acupuncture Society in London. Cummings said doctors in most developed countries recommend acupuncture for treating pain. In Brazil, acupuncture is recognized as a medical specialty. Cummings added that the treatment can be found in the British guidelines on managing headaches and is the only treatment recommended for the prevention of chronic tension headaches.

Cummings cited a large meta-analysis (published in 2017) of more than 20,000 patients that showed moderate benefit for acupuncture compared to usual care in patients with chronic pain. He said that a sham or fake form of acupuncture also had benefit, but less so than the real thing, which Cummings said adds to the plausibility of acupuncture as a bona fide treatment.  

Arguing against were Asbjørn Hrøbjartsson from the Centre for Evidence-Based Medicine and Edzard Ernst, an emeritus professor at the University of Exeter. The two argued that doctors should not recommend acupuncture for pain because there is insufficient evidence that acupuncture is worth the bother. They conceded that clinical trials comparing acupuncture with placebo show a small effect attributable to the Chinese treatment, but said the effect is clinically irrelevant, and cannot be distinguished from bias. 

Cochrane systematic reviews pore over published studies to try and answer medical questions. The two critics noted that not one of 12 Cochrane reviews of acupuncture for pain showed a clinically meaningful reduction in pain from conditions such as backache, rheumatoid arthritis, labour pain, and fibromyalgia. They added that the small benefit seen in some studies may be due to bias rather than acupuncture.  

The debate in the BMJ was published during a time when there has been a slow but steady drumbeat to ban acupuncture as a form of quackery. My sense is that those calls picked up a lot of steam last year, due in part to the opioid crisis, and the desire to find non-opioid treatments for pain. Last May, the U.S. Food and Drug Administration (FDA) released proposed changes to its blueprint for managing pain. The new guidelines recommended that doctors get information about acupuncture and chiropractic care as treatments that might help keep patients from taking opioids. 

On the cusp of gaining unprecedented respectability in Western medicine, critics decided to hit back hard by declaring that acupuncture and chiropractic are scientifically undeserving of FDA approval and recommendation. A lack of scientific evidence is one argument they're using. They also point to the risk of harm from acupuncture, whose adverse effects include punctured lung, infection, hemorrhages, and, in rare cases, death. Canadian researcher Dr. Andrea Furlan did a study showing that the harm caused by acupuncture is often not reported. 

Patients have their opinions too. Alongside the debate, the BMJ published a commentary by a patient named Kumari Manickasamy, who also happens to be a GP in London. Manickasamy wrote that she developed severe pelvic pain while pregnant with her second child. Similar pains during her first pregnancy were managed with physiotherapy as well as exercises, but the pain was much worse while carrying her second child. It got so bad she needed crutches just to walk around and her obstetrician offered to do an elective caesarean birth.

The GP knew a physiotherapist who did acupuncture and booked a session at a local clinic. She said felt better following the first treatment and continued to go for treatments once a week until the birth. In all, she said she experienced a modest degree of pain relief and was pleased that she did not need to increase her use of analgesics. She concluded that there seems to be a clear role for a safe and potentially effective treatment such as acupuncture.

I think science should guide doctors' recommendations. At best, the evidence in favour is weak and open to bias. Add to that the risk of harm, and it's hard to see how any western-trained doctor can justify recommending acupuncture to patients for most conditions.

The fact it's been around for thousands of years makes me think an outright ban is unlikely to be followed. That the FDA is looking for alternatives to opioids in the treatment of pain is laudable. But that does not justify suggesting to health practitioners that they consider acupuncture.

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