Applied Evidence

Acupuncture for pain: 7 questions answered

J Fam Pract. 2018 April;67(4):224-226,228-230

From The Journal of Family Practice | 2018;67(4):224-226,228-230.

References

1. Kennedy J, Roll JM, Schraudner T, et al. Prevalence of persistent pain in the U.S. adult population: new data from the 2010 National Health Interview Survey. J Pain. 2014;15:979-984.

2. U.S. Department of Health and Human Services. NIH Fact Sheet. Pain management. Available at: https://www.report.nih.gov/nihfactsheets/ViewFactSheet.aspx?csid=57. Accessed February 12, 2018.

3. Barnes PM, Bloom B, Nahin RL. Complementary and alternative medicine use among adults and children: United States, 2007. Natl Health Stat Report. 2008;12:1-23.

4. Nahin RL, Barnes PM, Stussman BJ, et al. Costs of complementary and alternative medicine (CAM) and frequency of visits to CAM practitioners: United States, 2007. Natl Health Stat Report. 2009;18:1-14.

5. Mayer DJ, Price DD, Rafii A. Antagonism of acupuncture analgesia in man by the narcotic antagonist naloxone. Brain Res. 1977;121:368-372.

6. Ammendolia C, Furlan AD, Imamura M, et al. Evidence-informed management of chronic low back pain with needle acupuncture. Spine J. 2008;8:160-172.

7. Zhang R, Lao L, Ren K, et al. Mechanisms of acupuncture-electroacupuncture on persistent pain. Anesthesiology. 2014;120:482-503.

8. Han JS. Acupuncture analgesia: areas of consensus and controversy. Pain. 2011;152(3 Suppl):S41-S48.

9. Chou R, Deyo R, Friedly J, et al. Nonpharmacologic therapies for low back pain: a systematic review for an American College of Physicians clinical practice guideline. Ann Intern Med. 2017;166:493-505.

10. Yuan J, Purepong N, Kerr DP, et al. Effectiveness of acupuncture for low back pain: a systematic review. Spine (Phila Pa 1976). 2008;33:E887-E900.

11. Linde K, Allais G, Brinkhaus B, et al. Acupuncture for the prevention of episodic migraine. Cochrane Database Syst Rev. 2016;6:CD001218.

12. Manheimer E, Cheng K, Linde K, et al. Acupuncture for peripheral joint osteoarthritis. Cochrane Database Syst Rev. 2010;1:CD001977.

13. Lin X, Huang K, Zhu G, et al. The effects of acupuncture on chronic knee pain due to osteoarthritis: a meta-analysis. J Bone Joint Surg Am. 2016;98:1578-1585.

14. Deare JC, Zheng Z, Xue CC, et al. Acupuncture for treating fibromyalgia. Cochrane Database Syst Rev. 2013;5:CD007070.

15. Vickers AJ, Cronin AM, Maschino AC, et al. Acupuncture for chronic pain: individual patient data meta-analysis. Arch Intern Med. 2012;172:1444-1453.

16. Qaseem A, Wilt TJ, McLean RM, et al, for the Clinical Guidelines Committee of the American College of Physicians. Noninvasive treatments for acute, subacute, and chronic low back pain: a clinical practice guideline from the American College of Physicians. Ann Intern Med. 2017;166:514-530.

17. Lee JH, Choi TY, Lee MS, et al. Acupuncture for acute low back pain: a systematic review. Clin J Pain. 2013;29:172-185.

18. Mayhew E, Ernst E. Acupuncture for fibromyalgia—a systematic review of randomized clinical trials. Rheumatology (Oxford). 2007;46:801-804.

19. Langhorst J, Klose P, Musial F, et al. Efficacy of acupuncture in fibromyalgia syndrome—a systematic review with a meta-analysis of controlled clinical trials. Rheumatology (Oxford). 2010;49:778-788.

20. Lao L, Hamilton GR, Fu J, et al. Is acupuncture safe? A systematic review of case reports. Altern Ther Health Med. 2003;9:72-83.

21. White A. A cumulative review of the range and incidence of significant adverse events associated with acupuncture. Acupunct Med. 2004;22:122-133.

22. Xu S, Wang L, Cooper E, et al. Adverse events of acupuncture: a systematic review of case reports. Evid Based Complement Alternat Med. 2013:581203.

23. Linde K, Allais G, Brinkhaus B, et al. Acupuncture for migraine prophylaxis. Cochrane Database Syst Rev. 2009;1:CD001218.

24. Dale R, Stacey B. Multimodal treatment of chronic pain. Med Clin North Am. 2016;100:55-64.

25. National Certification Commission for Acupuncture and Oriental Medicine. Available at: www.nccaom.org. Accessed March 20, 2018.

3. What does a typical acupuncture treatment entail?

In a typical treatment, anywhere from about 5 to 20 needles are inserted into the body. Common areas of needling include the arms and legs, especially below the elbows and knees. Other frequently used areas are the scalp, ears, and structures related to the painful condition.

The needles used are very thin (typically smaller than a 30-gauge needle) and do not have a beveled tip like phlebotomy needles do. Most patients have minimal pain as the needles are inserted. During the treatment, the needles may be left alone or they may be heated or stimulated electrically. An average treatment lasts 30 to 40 minutes; many patients find the sessions relaxing.

4. Are there any adverse effects or complications of treatment?

Acupuncture is generally considered a safe therapy, with most patients experiencing no adverse effects at all. Minor adverse effects can include post-treatment fatigue, minor bruising, or vasovagal reactions from the insertion of the needles. Serious complications, such as pneumothorax, are possible, but are considered rare.²⁰ A 2004 study estimated the incidence of severe complications to be .05 per 10,000 acupuncture treatments.²¹

Infections are also possible, but most reported cases were due to practitioners reusing needles.²² The standard of care in the United States is to use only sterilized, single-use needles. With this practice, infections due to acupuncture are thought to be rare.

Of note, trials that compare acupuncture to another active therapy often find that acupuncture has fewer adverse effects. This has been the case when acupuncture was compared to NSAIDs for low back pain and to topiramate for headaches.^17,23

5. How does acupuncture fit into a patient’s treatment?

The simple answer is that it is often most effectively used as part of a comprehensive management plan for chronic pain.

As our understanding of the complexity of chronic pain deepens, our therapeutic armamentarium for the management of chronic pain needs to broaden. This was summed up well in a 2016 article on the multimodal management of chronic pain when the authors stated, “Many targets need more than one arrow.”²⁴ Effective management of chronic pain involves addressing psychosocial and lifestyle factors in a patient-centered way and finding a combination of treatments that most effectively leads to improved coping and function.

It’s important to note that like medications and injections, acupuncture is a passive therapy. Although there is evidence for efficacy of improved pain with acupuncture in certain conditions, it should be combined with treatments that actively engage patients, such as exercise, behavioral treatments, development of coping skills, sleep hygiene, and educational strategies.

6. To whom do I refer patients for acupuncture treatment?

In the United States, licensed acupuncturists and physicians most commonly perform acupuncture. There are more than 50 schools that train licensed acupuncturists in the United States, and it usually takes 3 years to meet the requirements.²⁵

SIDEBAR
Online resources

American Academy of Medical Acupuncture
www.medicalacupuncture.com

National Center for Complementary and Alternative Medicine
http://nccam.nih.gov/health/acupuncture

National Certification Commission for Acupuncture and Oriental Medicine
www.nccaom.org

Physicians are often trained through continuing medical education (CME) programs that take several months to complete. These programs often combine live lectures, distance learning, and hands-on training and are typically sponsored by a university. Most require 300 hours of CME to complete. Licensure varies by state, but in many states, having an MD or DO degree automatically allows physicians to practice acupuncture. (See “Online resources,” above for links to Web sites that can be useful in finding qualified acupuncturists in your area.)

7. Is acupuncture covered by insurance?

Patients can expect to pay $75 to $150 for an acupuncture session.

It depends. Insurance coverage of acupuncture is highly variable and based on region and insurance type. Medicare and Medicaid plans do not pay for acupuncture. There are some private insurance plans that do. If covered, there may be limitations regarding diagnosis, number of visits, or provider. It is best for patients to call their insurance plan directly to inquire about coverage and any limitations. If paying out of pocket, patients can expect to pay $75 to $150 per treatment session.

CORRESPONDENCE
Russell Lemmon, DO, 1100 Delaplaine Court, Madison, WI 53715; russell.lemmon@fammed.wisc.edu.