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Should doctors recommend acupuncture for pain?

Mike Cummings, College of Medicine Lead for Acupuncture within Medicine and
Medical Director of the British Medical Acupuncture Society, expresses his views on whether doctors should prescribe acupuncture…

The evolution of this debate[1], should doctors recommend acupuncture for pain?, has been going on for more than a year, stimulated at first perhaps by some national media interest in a paper published in the journal Acupuncture in Medicine. [2]

The media interest had been whipped up to some degree by a well-known sceptic blogger, David Colquhoun. Colquhoun and I were interviewed briefly by John Humphrys on the BBC Radio 4 Today programme, and the editor-in-chief of The BMJ group was listening.

My perspective on the process can be read here.

A short time later I was asked if I would contribute in a ‘head-to-head’ debate on
acupuncture, and I negotiated over who was to be my opponent.

Several names of vocal sceptics were suggested, but I urged for an academic over a blogger, and in the end I got a mixture.

Much of the focus naturally fell on debating the relevance of the small effect of
acupuncture needling over a more gentle form of needling (‘sham’, ‘placebo’, ‘missing the
point’ acupuncture – the latter said with irony).

(Pictured: Dr Federico Campos modelling acupuncture)

 

There was little space to expand the argument to include the whole of what Sackett et al considered to be evidence: basic science and clinical expertise, as well as data from RCTs and systematic reviews.[3]

The process has given me insight and raised a diplomatic challenge. My opponents have
clearly never read a description of the modern (Western medical) approach to acupuncture
and its emphasis on stimulation of the deep soma over precise location of points. [4]

I agree with them to some extent; there is generally no clinically relevant effect to be
measured when you ‘miss the point’ in the control group. [5, 6]

Points are a useful construct for teaching and clinical practice, but in physiology, the realm of the actual mechanisms of acupuncture – precise points cannot be found, and therefore cannot be missed.

There are exceptions of course, where precision sometimes seems to pay off – primary myofascial pain for instance, but that is another chapter entirely.

To sum up, doctors should recommend acupuncture needling for patients in pain, [7, 8] and researchers should embrace the idea that it is difficult to miss the point when controlling for acupuncture.

References

1. Cummings M, Hróbjartsson A, Ernst E. Should doctors recommend acupuncture for pain? BMJ 2018;360:k970. https://www.bmj.com/content/360/bmj.k970

2. Landgren K, Hallström I. Effect of minimal acupuncture for infantile colic: a multicentre, three-armed, single-blind, randomised controlled trial (ACU-COL). Acupunct Med 2017;35:171–9. doi:10.1136/acupmed-2016-011208

3. Sackett DL, Rosenberg WM, Gray JA, et al. Evidence based medicine: what it is and what it isn’t. BMJ 1996;312:71–2.

4. Cummings M. Western Medical Acupuncture – The Approach to Treatment. In: Filshie J, White A, Cummings M, eds. Medical Acupuncture – A Western Scientific Approach. London: Elsevier 2016. 100–24.

5. Cummings M. Commentary: Controls for acupuncture – can we finally see the light? BMJ 2001;322:1578.pm:11431299

6. White A, Cummings M. Does acupuncture relieve pain? BMJ 2009;338:a2760. doi:10.1136/bmj.a2760

7. Cummings M. Author’s response III: Can we finally see the light? BMJ 2018;360:k970. doi:10.1136/bmj.k970 https://www.bmj.com/content/360/bmj.k970/rr-21

8. Cummings M. Author’s response IV: Needling is superior to conventional care in chronic back pain. BMJ 2018;360:k970. doi:10.1136/bmj.k970 https://www.bmj.com/content/360/bmj.k970/rr-24


Mike Cummings

College of Medicine Lead for Acupuncture within Medicine and Medical Director of the British Medical Acupuncture Society