Adapted and interpreted from Mark Bovey’s article in the Acu journal, Autumn 2020.
Mark Bovey is research manager at the British Acupuncture Council.
The National Institute for Health and Care Excellence (NICE) has just published a draft guideline for chronic pain. The guideline has had extensive media exposure, with the headline that “painkillers should no longer be prescribed for longer-term pain”. It is exciting that acupuncture is one of only four treatments now recommended.
Around a third of the population may be affected by chronic pain; many of those also have a diagnosis of depression, and two-thirds are unable to go out to work because of it. Thus the implications of these recommendations are enormous for UK healthcare policy and allocation of resources. NICE point out that current treatments of any sort are helpful for only a minority of the population and even then the benefits were considered modest.
This is NICE’s first guideline for chronic pain in general, rather than a specific painful condition, though the equivalent Scottish guideline agency (SIGN) has had one for several years (and it, too, endorses acupuncture). It is important to caution that this is not yet a done deal, not until final publication in January 2021. Although it’s very unlikely that there will be major shocks, some details may be changed.
It is also important to realise that this guideline excludes any condition whose pain management is addressed by existing NICE guidance, such as headaches, lower back pain, sciatica, osteoarthritis, rheumatoid arthritis, spondyloarthritis, endometriosis, and IBS.
This new guideline is for chronic primary pain, characterised by emotional distress and functional disability. Common conditions that would qualify are fibromyalgia, myofascial pain, chronic neck pain and chronic pelvic pain, though there are many more possibilities.
Which treatments are recommended by NICE in this guideline?
- exercise: a supervised group programme, preferably followed up long-term by patients themselves
- psychological therapies: specifically cognitive behavioural therapy (CBT) and acceptance and commitment therapy (ACT)
- antidepressant drugs: ten other classes of medication were considered and rejected, including opioids, anti-inflammatories, paracetamol, benzodiazepines and gabapentinoids: none of these was found to have evidence of benefit for chronic pain and there are possible harms associated with their use
What sort of acupuncture, what dose, and delivered by whom?
For NICE’s purposes it can be delivered by a traditional Chinese acupuncture or a western interpretation of acupuncture.
In order to try and keep a lid on the cost of rolling out new acupuncture services in the NHS, and to stay below the threshold indicated by their cost-effectiveness analysis, acupuncture should be:
- limited to a total of five hours treatment, which might typically mean ten half-hour sessions
- done in the community, not hospitals
- done by appropriately trained acupuncturists.
What did the acupuncture evidence show?
NICE included 32 studies in their review. They were looking for randomised controlled trials comparing traditional acupuncture either to sham acupuncture (acupuncture that stimulates non-acupuncture points) or to usual medical care. For pain, acupuncture was found to be superior to both sham acupuncture and usual care.
It is notable that all of the measures for mental health, psychological distress and sleep, both for sham acupuncture or usual care comparisons, showed benefits with acupuncture, underlining its ability to address symptoms and quality of life across a wide spectrum
Two existing studies, and a further analysis by NICE, showed fairly conclusively that acupuncture was cost-effective within a NHS framework.
What did the committee say in its summing up?
They agreed that there was good enough evidence that acupuncture was beneficial for pain. The recommendation is that NHS professionals should in future be allowed to consider the use of acupuncture, from appropriately trained acupuncturists, as an appropriate therapy to reduce pain.
Comment from GP spokespersons
They welcomed the guidance pointing out that drugs have been the main form of treatment to-date and although they recognised that drug therapy will not disappear, they saw the benefits of using fewer drugs and opting for acupuncture or the other recommended therapies as alternatives.
For more information and treatment contact Jill Owen on: https://jillowenacupuncture.co.uk/contact-jill