submitted by the Oregon Acupuncture Association (OAA) to the Oregon Pain Management Commission of the Oregon Health Authority January 2024
written by Kelly Ilseman, LAc/OAA Research Committee Chair,
with support from Kailashi Zigler, LAc/OAA Research Committee Member
Audience: Oregon Health Authority, Oregon Pain Management Commission, Medical Providers
Outline:
*Bullet Points
A. Supporting Agencies
B. Clinical Effectiveness
C. Cost-Effectiveness
D. Mechanisms
E. Insurance Coverage
F. References
Note: Due to the limited nature of the Wix blog platform, this material is divided into more than one post. This post includes supporting agencies and clinical effectiveness of acupuncture for pain and opioid dependence. See future posts for subsequent material on acupuncture for mental health, the mechanisms of acupuncture, and current basics on insurance coverage for acupuncture. Additionally, due to limitations posed by the Wix platform, AMA citations appear in parentheses rather than superscript.
*Bullet Points:A. Supporting Agencies: The use of acupuncture as an effective, evidence-based pain-management option has strong support from leading healthcare institutions. (1-7) B. Clinical Effectiveness: Acupuncture is a safe, effective, and evidence-based non-pharmacological pain management option for chronic and acute pain,(8-30) lower need for opioids,31-36 and improved mental-health outcomes,(37-53) and The benefits persist over time, further underscoring the cost-effectiveness of acupuncture. (9,54-69)
C. Cost-Effectiveness: Acupuncture and electroacupuncture are cost-effective first-line treatments for chronic pain (9,54-68) and for the opioid epidemic.(69)
D. Mechanisms: Biomedical understanding of the mechanisms of acupuncture is emerging at the forefront of biological research at a level of physiological detail on par with other biological science disciplines, and is understood to work via the connective tissue stimulating biochemical, bioelectrical, and molecular cascades, producing tangible physiological effects that can reduce pain and the experience of pain.(70-106)
E. Insurance Coverage: Leading Oregon health plans cover acupuncture for chronic pain management, including the Oregon Health Plan (OHP) as well as other private insurance carriers.(107-121)
A. Supporting Agencies
Acupuncture is supported as an effective, evidence-based pain-management option by the CDC,(1) the Centers for Medicare & Medicaid Services (CMS),(2) the Department of Veterans Affairs (DVA),(3) the American Academy of Pain Medicine (AAPM),(4) the American College of Physicians,(5) the FDA,(5) The Joint Commission, a hospital accrediting agency,(5) the National Academies of Science, Engineering, and Medicine,(5) the National Institutes of Health (NIH),(6) and the World Health Organization.(7)
B. Clinical Effectiveness of Acupuncture: Evidence-Based Research 1. Acupuncture for Pain
Hempel S, Shekelle PG, Taylor SL, Solloway MR. The evidence map of acupuncture. Department of Veterans Affairs VA-ESP Project #05-226. January 2014. https://www.hsrd.research.va.gov/publications/esp/acupuncture.pdf 8
● 1,223 studies electronically located, of which 183 met inclusion criteria (65 for pain, 44 for wellness, 20 for mental health, and 49 for “other”)
● Strong evidence of a positive effect from acupuncture found for headaches, chronic pain, and migraines
● Potential positive effects found for dysmenorrhea, osteoarthritis, general pain, cancer pain, labor pain, prostatitis, temporomandibular pain, plantar heel pain, pregnancy pain, and ankle sprain
● Unclear, but high-level, evidence found for back and neck pain
● Unclear evidence found for surgery analgesia, post-operative pain, fibromyalgia, shoulder pain, and rheumatoid arthritis
● No evidence found for effectiveness with carpal tunnel
McDonald J, Janz S. The acupuncture evidence project: a comparative literature review. Australian Acupuncture and Chinese Medicine Association. January 2017. (9)
● 122 conditions reviewed
● “Evidence of effect” found for 117 conditions
● No evidence of effect found for five conditions
● Level of “evidence of effect” increased for 24 conditions over time
● Positive acupuncture treatment effect for eight conditions: low back pain, migraines, knee osteoarthritis, headache, post-operative pain, chronic allergic rhinitis, and both chemotherapy-induced and post-operative nausea/vomiting.
● Cost-effectiveness identified for 10 conditions: chronic pain, low back pain, migraine, neck pain, osteoarthritis, ambulatory anesthesia, depression, dysmenorrhea, headache, post-operative nausea and vomiting, and allergic rhinitis.
● Evidence of safety identified for 9 conditions: low back pain, migraine, knee osteoarthritis, prostatitis pain, chronic pelvic pain, ambulatory anesthesia, Alzheimer's disease, cancer-related psychological symptoms, depression, and allergic rhinitis.
Conclusions: Acupuncture demonstrated a positive treatment effect for eight conditions: migraine prophylaxis, headache, chronic low back pain, allergic rhinitis, knee osteoarthritis, chemotherapy-induced nausea and vomiting, post-operative nausea and vomiting, and post-operative pain.
Vickers AJ, Cronin AM, Maschino AC, Lewith G, MacPherson H, Foster NE, et al. Acupuncture for chronic pain: individual patient data meta-analysis. Arch Intern Med. 2012;172(19):1444-53. (10)
39 studies involving 20,827 patients
True acupuncture significantly outperformed sham acupuncture (P < 0.001)
Treatment effects persisted over time, decreasing by only about 15% at one year
Referral for acupuncture is a reasonable clinical decision for chronic pain patients
Conclusions and a Note on Sham Acupuncture: Current knowledge that sham and placebo-controlled acupuncture both produce treatment effects has created a “consistent underestimation of the true effect size of acupuncture interventions” in previous acupuncture literature.
a. Acupuncture for Chronic Pain
i. Acupuncture for Chronic Low Back Pain
Xiang Y, He JY, Tian HH, Cao BY, Li R. Evidence of efficacy of acupuncture in the management of low back pain: a systematic review and meta-analysis of randomized placebo- or sham-controlled trials. Acupunct Med. 2020. Internet ISSN:1759-9873. (11)
● A systematic review involving fourteen trials (2,110 participants) and a meta-analysis involving 9 studies (753 participants) revealed that acupuncture produced “statistically significant differences in pain reduction” as compared with sham or placebo. A meta-analysis involving 4 studies (462 participants) showed “no differences in function.”
● At follow-up, acupuncture produced significant differences in pain reduction, but no differences in function.
● Authors concluded that moderate-level evidence exists for the efficacy of acupuncture in reducing subacute and chronic non-specific low back pain and that the benefits persist over time.
ii. Acupuncture for Chronic Neck Pain
Seo SY, Lee K-B, Shin J-S, Lee J, Kim M-R, Ha I-H, Ko Y, Lee YJ. Effectiveness of acupuncture and electroacupuncture for chronic neck pain: a systematic review and meta-analysis. Am J Chin Med. 2017;45(8):1573-1595. doi: 10.1142/S0192415X17500859. Epub 2017 Nov 9. (12)
● 16 randomized controlled trials were included.
● No significant differences in pain, disability, or quality of life (QoL) between acupuncture group versus active control.
● Acupuncture plus control group showed “significantly higher relief of pain in studies with unclear allocation concealment [a technique used to reduce selection bias]…, but did not show significant relief of pain in studies with good allocation concealment…”
● Electroacupuncture compared to the control and electroacupuncture plus control yielded significant pain relief.
● No serious adverse events.
● Acupuncture had “similar effectiveness on pain and disability” compared with conventional medicine; acupuncture plus conventional medicine provided even greater pain relief.
Trinh KV, Graham N, Gross AR, Goldsmith CH, Wang E, Cameron ID, Kay T. Acupuncture for neck disorders. Cochrane Database Syst Rev. 2006. (13)
10 randomized (RCT) or quasi-randomized (quasi-RCT) involving acupuncture treatment for chronic neck pain pooled for analysis
chronic mechanical neck disorders and pain
moderate evidence: acupuncture more effective than some sham controls (post-treatment)
moderate evidence: acupuncture more effective than sham controls (post-treatment and short-term follow-up) (pooled standardized mean difference (SMD) -0.37, 95% confidence interval (CI) -0.61 to -0.12).
limited evidence: acupuncture more effective than massage (short-term follow-up)
chronic neck disorders with radiculopathy
moderate evidence: acupuncture more effective than wait-list control (short-term follow-up)
Conclusions: Authors report moderate evidence that acupuncture relieves chronic neck pain better than some sham treatments, moderate evidence that acupuncture relieves pain better at short-term follow-up than waitlist control, and moderate evidence that acupuncture is better than inert sham controls for eliminating pain post-treatment and at short-term follow-up.
iii. Acupuncture for Episodic Migraine Pain
Giovanardi CM, Cinquini M, Aguggia M, Allais G, Campesato M, Cevoli S, Gentili F, Matra A, Minozzi S. Acupuncture vs. pharmacological prophylaxis of migraine: a systematic review of randomized controlled trials. Front Neurol. 2020 Dec 15;11:576272. doi: 10.3389/fneur.2020.576272. eCollection 2020. (14)
● Nine randomized trials involving 1,484 patients were analyzed.
● Acupuncture reduced the number of days with migraine per month, migraine response rate, a moderate reduction of migraine pain intensity, and a large reduction in dropout rate due to any reason and dropout rate due to adverse events.
● The quality of evidence was considered moderate for all outcomes.
● Treatment effects were still present at longest follow-up
● Conclusions: Acupuncture appears to be “mildly more effective and much safer than medication for the prophylaxis of migraine.”
iv. Acupuncture for Tension Headache Pain
Turkistani A, Shah A, Jose AM, Melo JP, Luenam K, Ananias P, Yaqub S, Mohammed L. Effectiveness of manual therapy and acupuncture in tension-type headache: a systematic review. Cureus. 2021;13(8):e17601. doi: 10.7759/cureus.17601. eCollection 2021 Aug. (15)
● Eight articles involving 3,846 participants were included in the analysis ● Acupuncture and manual therapy demonstrated effectiveness at treating tension-type headaches.
● Two large studies demonstrated moderate quality evidence that acupuncture plus routine care reduced headache frequency by an average of 50% compared with routine care alone.
● Trial 1: relative risk reduction (RRR) of 2.5; trial 2: RRR of 11.
● “Acupuncture was not found to be superior to physiotherapy, exercise, and massage therapy.”
● Manual therapy significantly decreased headache intensity.
● Manual therapy was equivalent to prophylactic medication and tricyclic antidepressants for tension headaches
● Conclusions: The available data suggests that both acupuncture and manual therapy have beneficial effects on treating symptoms of tension-type headache.
Linde K, Allais G, Brinkhaus B, et al. Acupuncture for the prevention of tension-type headache. Cochrane Database Syst Rev. 2016;(4):CD007587. (16)
● Twelve studies with publication dates through January 2016 involving 2,349 adult patients, plus one additional new trial, were pooled and analyzed.
● Acupuncture plus usual care for acute migraine yielded 48/100 participants with a 50% or greater reduction in headache frequency versus 17/100 for usual care.
● Acupuncture compared with sham acupuncture resulted in 52/100 participants with a 50% or greater reduction in headache frequency versus 43/100 for sham acupuncture. The results from true acupuncture were long-lasting, up to 6 months after treatments.
v. Acupuncture for Osteoarthritis Pain
Lin L-L. TU J-F, Wang L-Q, Yang J-W, Shi G-X, Li J-L, Zhang N, Shao J-K, Zou X, Liu C-Z. Acupuncture of different treatment frequencies in knee osteoarthritis: a pilot randomised controlled trial. Pain. 2020;161(11):2532-2538. doi: 10.1097/j.pain.0000000000001940 (17)
● Sixty participants were randomized to three sessions per week of acupuncture (TSWA) or one session per week of acupuncture (OSWA) groups in a 1:1 ratio
● Week 8: no significant differences in response rate between the TSWA and OSWA treatment groups (P = 0.435)
● Weeks 4 and 16: TSWA had significant differences in response rate compared to OSWA (week 4: difference, 44.7 percentage points; P = 0.001) and (week 16: difference, 46.0 percentage points; P < 0.001).
● The TSWA group had statistically significant improvements in numerical rating scale (NRS), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) function, and Patient Global Assessment than the OSWA group. No significant between–group differences were found for WOMAC and Short Form Health Survey (SF-12).
● An acupuncture dose-response relationship for knee osteoarthritis pain and function clinical outcomes exists.
● “TSWA immediately improved knee pain and dysfunction compared with OSWA [and] the benefit of TSWA persist[ed] throughout follow-up.”
Sun N, TU JF, Lin LL, et al. Correlation between acupuncture dose and effectiveness in the treatment of knee osteoarthritis: a systematic review. Acupunct Med. 2019;37(5):261-267. https://doi.org/10.1136/acupmed-2017-011608 (18)
● Eight studies (1 LD, 1 MD, and 6 HD) included for analysis involving 2,106 participants.
● The authors concluded that there was “strong evidence” of a “positive correlation between HD [high dose] acupuncture treatment and positive outcomes.”
Chen N, Wang J, Mucelli A, et al. Electro-acupuncture is beneficial for knee osteoarthritis: the evidence from meta-analysis of randomized controlled trials. Am J Chin Med. 2017;45(5):965-985. (19)
● Eleven randomized controlled trials including 695 participants were included in the analysis to assess the safety and effectiveness of electroacupuncture (EA) for knee osteoarthritis.
○ EA was statistically more effective:
■ than pharmacological interventions (P = 0.03) and manual acupuncture (P = 0.02)
■ at reducing pain intensity (P<0.00001), improving physical function WOMAC scores (P<0.00001), and improving Lysholm knee score (LKSS) (P<0.00001).
● Electroacupuncture had significant clinical outcomes for improved pain and physical function compared to pharmacological interventions and manual acupuncture; EA has “low risk of adverse reaction.”
Manheimer E, Cheng K, Linde K, et al. Acupuncture for peripheral joint osteoarthritis. Cochrane Database Syst Rev. 2010;(1):C0001977. (20)
● Sixteen trials (12 knee O A; 3 hip OA; 1 hip and knee OA) involving 3,498 participants were included.
● Acupuncture versus sham yielded statistically significant “short-term improvements in osteoarthritis pain.”
● Acupuncture versus sham yielded statistically significant improvements in function.
● Neither of these results met the authors’ “predefined thresholds for clinical relevance.”
● Inclusion of sham acupuncture, known to be physiologically active, affected results.
● At 6 month follow-up acupuncture showed “borderline” statistical significance and “clinically irrelevant improvements” for osteoarthritis pain and function as compared to sham.
● Acupuncture versus waitlist control showed statistically significant and clinically meaningful results for osteoarthritis pain and function.
● Acupuncture versus ‘supervised osteoarthritis education’ and ‘physician consultation’ control groups showed “clinically relevant short- and long-term improvements in pain and function.”
● Acupuncture versus ‘home exercises/advice leaflet’ and ‘supervised exercise’ had similar outcomes as controls.
● Acupuncture plus “exercise based physiotherapy program” had similar outcomes as the exercise program without acupuncture.
vi. Acupuncture for Cancer Pain
Yang J, Wahner-Roedler DL, Zhou X, Johnson LA, Do A, Pachman DR, Chon TY, Salinas M, Millstine D, Bauer BA. Acupuncture for palliative cancer pain management: systematic review. BMJ Support Palliat Care. 2021 Sep;11(3):264-270. doi: 10.1136/bmjspcare-2020-002638. Epub 2021 Jan 13. (21)
5 studies involving 189 patients pooled for meta-analysis
Results: acupuncture demonstrated “favourable effect of acupuncture on pain relief in palliative care for patients with cancer”
Oxford Centre for Evidence-Based Medicine (OCEBM) evidence levels showed 40% at level 4, 30% at level 3, and 20% at level 2
Conclusions: “Acupuncture may be an effective and safe treatment associated with pain reduction in the palliative care of patients with cancer.”
Mao M, Liou KT, Baser RE, Bao T, Panageas KS, Romero SD, Li S, Gallagher RM, Kantoff PW. Effectiveness of electroacupuncture or auricular acupuncture vs usual care for chronic musculoskeletal pain among cancer survivors: the PEACE randomized clinical trial. JAMA Oncol. 2021 May 1;7(5):720-727. doi: 10.1001/jamaoncol.2021.0310. (22)
Randomized clinical trial (Personalized Electroacupuncture vs Auricular Acupuncture Comparative Effectiveness - PEACE) conducted from March 2017 to April 2020
360 cancer survivors (mean age 62.1) chronic musculoskeletal pain and no current detectable cancer participated from urban and suburban sites in New York and New Jersey
Outcome assessment: Brief Pain Inventory (BPI) rating scale 0-10
Treatment groups: electroacupuncture (N = 145), auricular acupuncture (N = 143), usual care (N = 72)
Number of treatments: 10 acupuncture treatments (1 session/week for 10 weeks plus follow-up)
Results: Pain severity lowered by 1.9 points in the electroacupuncture group vs usual care group from initial assessment to week 12 (97.5% CI, 1.4-2.4 points; P < .001)
Pain severity lowered by 1.6 points in the auricular acupuncture group vs usual care from initial assessment to week 12 (97.5% CI, 1.0-2.1 points; P < .001)
Mild adverse effects for 15/143 (10.5%) of auricular participants and 1/145 (0.7%) of electroacupuncture participants, who dropped out of the study as a result (P < .001)
Conclusions: “Electroacupuncture and auricular acupuncture produced greater pain reduction than usual care” in treating cancer survivors’ chronic musculoskeletal pain.
He Y, Guo X, May BH, Zhang AL, Liu Y, Lu C, Mao JJ, Xue CC, Zhang H. Clinical evidence for association of acupuncture and acupressure with improved cancer pain: a systematic review and meta-analysis. JAMA Oncol. 2020 Feb 1;6(2):271-278. doi: 10.1001/jamaoncol.2019.5233. (23)
14 randomized controlled trials (RCTs) in English and Chinese involving 920 cancer pain patients pooled for meta-analysis
Acupuncture and acupressure compared with sham acupuncture, analgesic therapy, and standard care
Primary outcomes: pain levels measured by the Brief Pain Inventory, Numerical Rating Scale, Visual Analog Scale, Verbal Rating Scale.
7 sham-controlled RCTs demonstrated that acupuncture compared to sham was superior for reducing cancer pain (mean difference [MD], -1.38 points; 95% CI, -2.13 to -0.64 points; I2 = 81%)
these 7 studies considered high quality with low bias risk
6 RCTs with treatments combining acupuncture and acupressure with analgesic therapy showed a “favorable association” with pain reduction (MD, -1.44 points; 95% CI, -1.98 to -0.89; I2 = 92%)
moderate evidence grade (study heterogeneity)
2 RCTs with treatments combining acupuncture and acupressure with analgesic therapy showed a “favorable association” with opioid dosage reduction (MD, -30.00 mg morphine equivalent daily dose; 95% CI, -37.5 mg to -22.5 mg)
moderate evidence grade (study heterogeneity)
Conclusions: “acupuncture and/or acupressure was significantly associated with reduced cancer pain and decreased use of analgesics.”
b. Acupuncture for Acute Pain
Nielsen A, Dusek JA, Taylor-Swanson L, Tick H. Acupuncture therapy as an evidence-based nonpharmacologic strategy for comprehensive acute pain care: the academic consortium pain task force white paper update. Pain Med. 2022;23(9):1582–1612. https://doi.org/10.1093/pm/pnac056 (24)
Objective: Researchers sought to update the 2018 white paper on acupuncture for acute “postsurgical/perioperative pain with opioid sparing and acute nonsurgical/trauma pain”
Methods: Systematic review of PubMed, MEDLINE, CINAHL, and Cochrane Central Register of Controlled Trials; keywords: “acupuncture” and “acupuncture therapy” and “acute pain,” “surgery,” “peri-operative,” “trauma,” “emergency department,” “urgent care,” “review(s) ,” “systematic review,” “meta-analysis.” “Additional manual review of titles, links, and reference lists”
Results: 22 systematic reviews included for review (including 17 meta-analyses of acupuncture for acute pain, and 1 review of acupuncture for acute pain in intensive care unit)
Conclusion. “The majority of reviews found acupuncture therapy to be an efficacious strategy for acute pain, with potential to avoid or reduce opioid reliance.”
i. Acupuncture for Acute Pancreatic Pain
Zhu F, Yin S, Zhu X, Che D, Li Z, Zhong Y, Yan H, Gan D, Yang L, Wu X, Li L. Acupuncture for relieving abdominal pain and distension in acute pancreatitis: a systematic review and meta-analysis. Front Psychiatry. 2021;12:Article 786401. doi:10.3389/fpsyt.2021.786401 (25)
● Nineteen studies involving 1,503 participants were included
● Acupuncture plus routine treatment (RT) produced significant increases in total effectiveness rate (P = 0.001)
● Acupuncture reduced visual analog scale (VAS) scores for abdominal pain (P < 0.0001) and for abdominal distension (P < 0.0001)
● Conclusion: Acupuncture plus RT reduced abdominal pain and distention in patients with acute pancreatitis better than RT alone.
Zhang K, Gao C, Li C, Li Y, Wang S, Tang Q, Zhao C, Zhai J. Acupuncture for acute pancreatitis: a systematic review and meta-analysis. Pancreas. 2019;48(9):1136-1147. doi: 10.1097/MPA.0000000000001399 (26)
● Twelve studies were included in the final analysis.
● Acupuncture plus routine treatment (RT) versus RT alone significantly improved total effectiveness rate and gastrointestinal function.
● Acupuncture plus routine treatment (RT) versus RT alone significantly reduced “acute physiology, Age, Chronic Health Evaluation II score, tumor necrosis factor α count,” the time until resumption of regular diet, and length of stay in the hospital.
● 3 studies reported minor adverse events or reactions.
ii. Acupuncture for Acute Low Back Pain
Su X, Qian H, Chen B, Fan W, Xu D, Tang C, Lu L. Acupuncture for acute low back pain: a systematic review and meta-analysis. Ann Palliat Med. 2021;10(4):3924-3936. http://dx.doi.org/10.21037/apm-20-1998 (27)
● Thirteen RCTs met inclusion criteria.
● Eleven RCTs involving 707 participants demonstrated “moderate-quality evidence that acupuncture has a statistically significant association with improvements in VAS (visual analog scale) score.”
● Two studies showed no impact upon RMDQ (Roland-Morris Disability Questionnaire) scores for low back pain effects on functional activities compared with the control. ● Three studies showed that acupuncture impacted the ODI (Oswestry Disability Index) low back pain scores compared with the control.
● Two studies demonstrated that acupuncture “influenced the number of pills more than the control treatment.”
● The use of acupuncture for treating low back pain showed “modest improvements in the VAS score, ODI score, and the number of pills, but not the RMDQ score.”
Cho Y-H, Kim C-K, Heo K-H, Lee MS, Ha I-H, Son DW, Choi BK, Song G-S, Shin B-C. Acupuncture for acute postoperative pain after back surgery: a systematic review and meta-analysis of randomized controlled trials. Pain Pract. 2015;15(3):279-91. doi: 10.1111/papr.12208. Epub 2014 Apr 28. (28)
● Five studies met the inclusion criteria. Three of these were high-quality. ● Acupuncture for acute post-operative pain showed beneficial impact on “visual analogue scale (VAS) for pain intensity 24 hours after surgery” compared with sham acupuncture (P = 0.0003).
● Acupuncture did not show a beneficial impact on 24-hour opiate demands compared with sham acupuncture (P = 0.21).
● Conclusion: “Encouraging but limited evidence [exists] for the effectiveness of acupuncture treatment for acute postoperative pain after back surgery”
Lee J-H, Choi T-Y, Lee MS, Lee H, Shin B-C, Lee H. Acupuncture for acute low back pain: a systematic review. Clin J Pain. 2013;29(2):172-85. doi: 10.1097/AJP.0b013e31824909f9. (29)
● Eleven RCTs involving 1,139 participants were included for analysis.
● Compared with nonsteroidal anti-inflammatory drugs (NSAIDs), acupuncture more effectively relieved acute low back pain in 5 studies.
● Acupuncture was more effective than sham acupuncture for pain relief, but was not more effective for function/disability.
● Conclusion: “Acupuncture may be more effective than medication for symptom improvement or relieve pain better than sham acupuncture in acute LBP.”
iii. Acupuncture for Acute Post-Tonsillectomy Pain
Gilbey P, Bretler S, Avraham Y, Sharabi-Nov A, Ibrgimov S, Luder A. Acupuncture for posttonsillectomy pain in children: a randomized, controlled study. Pediatr Anesth. 2014. doi: 10.1111/pan.12621 (30)
Methods: Randomized, controlled, single-blinded study Population: 60 children aged 3–12 years undergoing tonsillectomy Treatment Groups: acupuncture group and conventional postoperative analgesic treatment group
Outcome Assessment: pain levels and presence of unwanted side effects
Results: Acupuncture group experienced “less pain, less analgesic drug consumption, and higher patient/parent satisfaction with analgesic treatment scores. No adverse effects were recorded.”
Conclusions: “Acupuncture, in addition to conventional analgesic treatment, is an effective treatment for post-tonsillectomy pain. Acupuncture is safe and well received by children and their parents.”
2. Acupuncture for Opioid Use Reduction
a. Acupuncture for Opioid Use Reduction During/After Surgical Procedures
Cheng SI, Kelleher DC, DeMeo D, Zhong H, Birch G, Ast MP. Intraoperative acupuncture as part of a multimodal analgesic regimen to reduce opioid usage after total knee arthroplasty: a prospective cohort trial. Med Acupunct. 2022; 34(1). doi: 10.1089/acu.2021.0072 (31)
● 41 patients participated in this study.
● Electro-auricular acupuncture used intraoperatively as part of an analgesia protocol for patients undergoing total knee arthroplasty surgery helped to reduce the need for opioids after surgery.
● 26/40 (65%) participants maintained low-dose opioid intake.
● Three participants (7%) were opioid-free for 30 days, and 100% of participants were opioid-free after 30 days.
Pham T, Ma O, Agiro A, Bukowiec J, Flannery T. Do acupuncture services reduce subsequent utilization of opioids and surgical interventions compared to noninvasive therapies among patients with pain conditions? Pain Med. 2021;22(11):2754-2762. doi: 10.1093/pm/pnab187 (32)
● This was a retrospective observational study of administrative claims from large commercial insurance plans involving 52,346 patients treated with either acupuncture or non-steroidal anti-inflammatory drugs (NSAIDs) or physical therapy (PT)
● Acupuncture treatment group resulted in lower patient use of post-index opioid use for those “with (P < .001) and without (P < .001) baseline opioid use.”
● Acupuncture use resulted in a lower number of emergency department visits (P < .001).
● A small increase in invasive surgical procedures occurred with the acupuncture group (P = .006).
● Acupuncture use resulted in higher total medical and pharmacy costs (P = .006). ● Conclusion: Acupuncture reduced opioid use and emergency department visits.
Tedesco D, Gori D, Desai KR, Asch S, Carroll IR, Curtin C, McDonald KM, Fantini MP, Hernandez-Boussard T. Drug-free interventions to reduce pain or opioid consumption after total knee arthroplasty. JAMA Surg. 2017; 152(10): e172872. doi: 10.1001/jamasurg.2017.2872 (33)
● 39 randomized clinical trials involving 2,391 patients were included.
● There was moderate certainty evidence that electrotherapy reduced opioid use from -5.90 to -1.10 mg/kg morphine equivalents per 48 hours (P = .004).
● There was moderate yet statistically significant evidence that acupuncture delayed opioid use (P < .001).
● There was low certainty yet statistically significant evidence for acupuncture reducing pain (P = .003).
● Electrotherapy and acupuncture after total knee arthroplasty surgery are associated with reduced and delayed opioid consumption.
b. Acupuncture for Opioid Addiction Treatment
Wen H, Wei X, Ge S, Zeng J, Luo W, Chen R, Dong Y, Xiao S, Lai Y, Lu L. Clinical and economic evaluation of acupuncture for opioid-dependent patients receiving methadone maintenance treatment: the integrative clinical trial and evidence-based data. Front Public Health. 2021;9:1-12. (34)
● This study involved 123 patients.
● Participants who received acupuncture and methadone maintenance treatment (MMT) had significantly improved daily methadone dosage, visual analog scores (VAS), and Pittsburgh Sleep Quality Index (PSQI).
● These treatments were shown to be “economically efficient.”
● Quality-Adjusted Life Year (QALY), a generic measure that includes both quality and quantity of life, and cost were higher for the treatment group versus the control group.
● The authors concluded that acupuncture serves as a clinically effective, cost-effective “adjuvant therapy” for MMT patients, “reducing the dosage of methadone, improving drug cravings, and alleviating insomnia,” as well as improving quality of life.
Jackson HJ, Walters J, Raman R. Auricular acupuncture to facilitate outpatient opioid weaning: a randomized pilot study. Med Acupunct. 2021;33(2):153-158. doi: 10.1089/acu.2020.1450 (35)
● “A total of 9 participants were randomized into the intervention group and compared with 6 participants who underwent the standard of care for outpatient opioid tapering.” ● Anxiety was found to be slightly higher and depression was found to be lower in the acupuncture group versus the standard of care group.
● The standard of care group had greater withdrawal symptoms and higher pain levels. Researchers found “no statistically significant differences among the standard of care and acupuncture groups.”
● Although the impact of acupuncture treatment was not statistically significant compared with standard of care, researchers suggested that the auricular acupuncture NADA protocol can be easily and effectively incorporated into standard of care for opioid tapering.
● Due to the small size of this study, future larger studies are recommended to determine treatment effects.
Chen Z, Wang Y, Wang R, Xie J, Ren Y. Efficacy of acupuncture for treating opioid use disorder in adults: a systematic review and meta-analysis. Evid Based Complement Altern Med. (36)
● Nine studies involving 1,063 participants were included.
● Acupuncture was found to be more useful than no treatment or sham treatment to reduce opioid craving, insomnia, and depression.
● Electroacupuncture did a better job than sham electroacupuncture or transcutaneous electrical acupoint stimulation (TEAS) to alleviate craving and depression.
● TEAS alleviated symptoms of insomnia and anxiety compared to no treatment or sham.
● Authors concluded that there is evidence supporting the use of acupuncture, electroacupuncture, and TEAS to relieve opioid cravings, insomnia, anxiety, and depression, but that “conclusions were limited due to the low-quality and small number of included studies.”
F. References
1. Center for Disease Control. Opioid Prescription Guidelines. Accessed January 8, 2024, from https://www.cdc.gov/mmwr/volumes/71/rr/rr7103a1.htm?s_cid=rr7103a1_w.
2. Centers for Medicaid and Medicaid Services (CMS). Decision Memo for Acupuncture for Chronic Low Back Pain (CAG-00452N). Accessed March 31, 2022, from https://www.cms.gov/medicare-coverage-database/details/nca-decision-memo.aspx?NCAId=29
3. U.S. Department of Veterans Affairs. Veterans Health Administration. Acupuncture in VA - Fact Sheet. Accessed on January 8, 2024, from
https://www.va.gov/WHOLEHEALTH/docs/AcupunctureFactSheet_508.pdf#:~:text=This%20allowed%20acupuncture%20care%20to%20be%20created%20by,provide%20acupuncture%20care %20 at%20 VA%20Medical%20center%20%28VAMC%29
4. Stanos SP. Stemming the tide of the pain and opioid crisis: AAPM reaffirms its commitment to multidisciplinary biopsychosocial care and training. Pain Med. 2017;18:1005–1006. doi:10.1093/pm/pnx120
5. Gong C-Z, Liu W. Acupuncture and the opioid epidemic in america. Chin J Integr Med. 2018;24(5):323-327.
6. NIH. NIH Consensus Conference. Acupuncture. JAMA. 1998;280(17):1518–1524.
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