As recently reported, the most thorough review of the subject showed that the evidence for acupuncture as a treatment for chronic pain is very weak. Yesterday, NICE published a draft report that seems to somewhat disagree with this conclusion (and today, this is being reported in most of the UK daily papers). The draft is now open to public consultation until 14 September 2020 and many of my readers might want to comment.
The draft report essentially suggests that people with chronic primary pain (CPP) should not get pain-medication of any type, but be offered supervised group exercise programmes, some types of psychological therapy, or acupuncture. While I understand that chronic pain should not be treated with long-term pain-medications – I did even learn this in medical school all those years ago – one might be puzzled by the mention of acupuncture.
But perhaps we need first ask, WHAT IS CPP? The NICE report informs us that CPP represents chronic pain as a condition in itself and which can’t be accounted for by another diagnosis, or where it is not the symptom of an underlying condition (this is known as chronic secondary pain). I find this definition most unsatisfactory. Pain is usually a symptom and not a disease. In many forms of what we now call CPP, an underlying disease does exist but might not yet be identifiable, I suspect.
The evidence on acupuncture considered for the draft NICE report included conditions like:
- neck pain,
- myofascial pain,
- radicular arm pain,
- shoulder pain,
- prostatitis pain,
- mechanical neck pain,
- vulvodynia.
I find it debatable whether these pain syndromes can be categorised to be without an underlying diagnosis. Moreover, I find it problematic to lump them together as though they were one big entity.
The NICE draft document is huge and far too big to be assessed in a blog like mine. As it is merely a draft, I also see little point in evaluating it or parts of in detail. Therefore, my comments are far from detailed, very brief and merely focussed on pain (the draft NICE report considers several further outcome measures).
There is a separate document for acupuncture, from which I copy what I consider the key evidence:
Acupuncture versus sham acupuncture
Pain reduction
Very low quality evidence from 13 studies with 1230 participants showed a clinically
important benefit of acupuncture compared to sham acupuncture at ≤3 months. Low quality
evidence from 2 studies with 159 participants showed a clinically important benefit of
acupuncture compared to sham acupuncture at ≤3 months.
Low quality evidence from 4 studies with 376 participants showed no clinically important
difference between acupuncture and sham acupuncture at >3 months. Moderate quality
evidence from 2 studies with 159 participants showed a clinically important benefit of
acupuncture compared to sham acupuncture at >3 months. Low quality evidence from 1
study with 61 participants showed no clinically important difference between acupuncture
and sham acupuncture at >3 months.
As acupuncture has all the features that make a perfect placebo (slightly invasive, mildly painful, exotic, involves touch, time and attention), I see little point in evaluating its efficacy through studies that make no attempt to control for placebo effects. This is why the sham-controlled studies are central to the question of acupuncture’s efficacy, no matter for what condition.
Reading the above evidence carefully, I fail to see how NICE can conclude that CPP patients should be offered acupuncture. I am sure that some readers will disagree and am looking forward to reading their comments.
11 Responses to Draft guidelines from NICE on treatments for chronic primary pain. Part 1: ACUPUNCTURE
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I agree with you. Their section on evidence for acupuncture is littered with reference to low quality trials.
Chen et al; J Osteoarthritis and cartilage. May 13, 2020: “Pain relief experienced by patients with osteoarthritis (OA) of the knee may be attributed to contextual-effect, especially in those patients receiving acupuncture or electrotherapies. This was the first study to quantify the contextual effect of nonpharmacologic, nonsurgical treatments (NPNS) on knee OA. Previous studies have examined the placebo effect, “an important component of the contextual effect,” the researchers said. “Contextual effect may include the placebo effect, changes attributable to natural history, and effects of cotherapies. These factors can influence therapeutic outcomes substantially.”
OA is most certainly NOT a primary chronic pain
From pp 5-6 of the Draft Scope: https://www.nice.org.uk/guidance/GID-NG10069/documents/draft-scope
“1 The term ‘non-specific’ persistent pain is used here to include conditions that may be recorded as
fibromyalgia, complex regional pain syndrome, myofascial pain, somatoform disorder, functional
syndromes, chronic widespread pain, pelvic pain of unknown origin.”
“Areas that will not be covered
125 1 Specific management of pain covered by related NICE guidance:
126 endometriosis, headaches, irritable bowel syndrome, low back pain and
127 sciatica, rheumatoid arthritis, osteoarthritis and spondyloarthritis.”
I âgree with your comments regarding acupuncture. However you do not appear to be aware of the new propsed ICD – 11 CLassification of chronic pain and the reasons for this. There has been debate around this proposal. See
https://pubmed.ncbi.nlm.nih.gov/30586068/
I dont see why the nociceptive system can’t go wrong in its own right and that chronic pain is not allways a symptom of disease. You may well be right that at this stage what we are calling chronic primary pain may in the future have a diagnosable cause, but at the moment we can’t find one. The “disease” of chronic pain would not satisfy the strict scientific criteria for one. More useful to think of associated consequences of living with chronic pain.
“I dont see why the nociceptive system can’t go wrong in its own right and that chronic pain is not allways a symptom of disease.”
sure
but mechanical neck pain, for instance???
For instance…
“This article highlights the presentation, differential diagnosis, and appropriate work-up for the patient who presents with mechanical neck pain.”
Neurosurgery, Volume 60, Issue suppl_1, January 2007, Pages S1-21–S1-27
The NICE news page is slightly misleading. In the draft guideline NICE say that patients with chronic primary pain should be offered supervised group exercise. NICE also say that two specified psychological therapies, and also acupuncture and antidepressants should be considered offering to patients. Exercise should be offered but the other therapies are at the doctors’ discretion.
Psychological therapies and antidepressants are deemed to be as useful as sticking needles into the body. That’s rather bad news for psychological therapies and even worse news for psychotherapy which isn’t recommended. Nor is relaxation or mindfulness recommended due to insufficient evidence. Loads of fetid evidence is sufficient for NICE as long as a treatment is safe.
The take home message for chronic pain sufferers is to take exercise classes.
What does NICE find in acupuncture trials?
Quality of RCTs: Abysmal. Heterogeneity: Horrific. Risk of bias: Stewing in it. Population? Female almost to a woman. What does the evidence amount to? Works for chronic neck pain and fibromyalgia in women. What can acupuncture be used for? All chronic pain conditions.
Is NICE nodding through nonsense for chronic pain?
That’s left to the doctor’s discretion, nudge nudge.
Oh boy. Here’s a new one to me.
Psychological accupuncture.
https://www.healthline.com/health/eft-tapping#treatment
https://edzardernst.com/2018/10/emotional-freedom-technique-a-combination-of-two-types-of-bs/
Science Based Medicine on the subject.
https://sciencebasedmedicine.org/uk-recommendations-wrong-on-acupuncture/