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New UK guidance: Acupuncture rather than drugs for chronic pain

There have been some raised eyebrows at the UK medical guidelines body's draft guidelines on the management of chronic pain punting acupuncture, despite what the critics say is poor evidence of its efficacy, writes MedicalBrief.

Acupuncture should be used to treat chronic pain rather than opiates, according to new guidance for GPs and sufferers. The Daily Telegraph reports that the draft guidelines, released by NICE (National Institute of Health and Care Excellence), states that commonly used drug treatments for chronic pain have “little or no evidence that they work”.

Instead, physical exercise, psychological therapy, antidepressants or acupuncture, should be offered to patients, it says. Chronic primary pain is a condition which cannot be attributed to another diagnosis and is often characterised by significant emotional distress, such as anxiety or depression, as well as causing disability in daily life tasks. It is estimated to affect between one third and one half of the population.

The report says the new NICE guidance, which is open for public consultation until 14 September, recommends that some antidepressants should be considered as treatment, after a review of evidence found they “improved quality of life, pain and psychological distress compared with placebo”.

But the committee ruled against the recommendation of pain management drugs, such as paracetamol, non-steroidal anti-inflammatory drugs (these include aspirin and ibuprofen), benzodiazepines and opioids.

“The lack of evidence for effectiveness of opioids, along with evidence of long-term harm, persuaded the committee to recommend against opioid use for people with chronic primary pain,” the guidance says. It comes as health experts recently warned opioid painkillers do not work for nine in 10 people with chronic pain.

The guidelines also advise against antiepileptic drugs, such as local anaesthetics and ketamine, as there was also little or no evidence that they work, but they could cause harm. Instead, treatments such as a group exercise programme or cognitive behavioural therapy (CBT) are recommended.

The committee also said “a course of acupuncture or dry needling, within a traditional Chinese or Western acupuncture system” should be considered to treat chronic primary pain. But only if it is delivered within a community setting by a health care professional. Explaining the rationale for its recommendation the committee said 27 studies have shown acupuncture reduced pain and improved quality of life in as little as three months, “compared with usual care or sham acupuncture”. But it added there is not enough evidence to assess its long-term effectiveness.

The guidance went on to add: “The committee acknowledged the difficulty in blinding for sham procedures, but agreed that the benefit compared with a sham procedure indicated a specific treatment effect of acupuncture.”

Complementary medicines expert, Emeritus Professor Edzard Ernst, writes in his blog that he is "puzzled" at the NICE recommendation on acupuncture. He cites the "key evidence" considered by NICE on acupuncture versus sham acupuncture, as regards 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," writes Ernst.

Paul Chrisp, director of the Centre for Guidelines at NICE, said in the report that the guidance highlights the importance of communication when it comes to caring for those with chronic pain. “When many treatments are ineffective or not well tolerated it is important to get an understanding of how pain is affecting a personʼs life and those around them because knowing what is important to the person is the first step in developing an effective care plan,” he said.

Nick Kosky, a consultant psychiatrist at Dorset HealthCare NHS University Foundation Trust and chair of the guideline committee, said a contrast between patient expectations and treatment outcomes can impact their relationship with doctors. “Understandably, people with chronic pain expect a clear diagnosis and effective treatment. But its complexity and the fact GPs and specialists alike find chronic pain very challenging to manage, means this is often not possible,” he said. “This mismatch between patient expectations and treatment outcomes can affect the relationship between healthcare professionals and patients, a possible consequence of which is the prescribing of ineffective but harmful drugs.”

The new guidance will help to improve this relationship, Kosky is quoted in The Telegraph as saying, by “fostering a clearer understanding of the evidence for the effectiveness of chronic pain treatments”.

 

Painkillers such as paracetamol, ibuprofen, aspirin and opioids can do “more harm than good” and should not be prescribed to treat chronic pain. And, The Guardian quotes health officials at NICE as saying, the draft guidance said there was evidence they can cause harm, including addiction.

Kosky, said that, while patients expected a clear diagnosis and effective treatment, the complexity of the condition means GPs and specialists can find it very “challenging” to manage. The consultant psychiatrist at Dorset Healthcare NHS University foundation trust added: “This mismatch between patient expectations and treatment outcomes can affect the relationship between healthcare professionals and patients, a possible consequence of which is the prescribing of ineffective but harmful drugs.

“This guideline, by fostering a clearer understanding of the evidence for the effectiveness of chronic pain treatments, will help to improve the confidence of healthcare professionals in their conversations with patients.

“In doing so it will help them better manage both their own and their patients’ expectations.”

According to the report, the draft guideline also said that anti-epileptic drugs including gabapentinoids, local anaesthetics, ketamine, corticosteroids and anti-psychotics should not be offered to people to manage chronic primary pain because, again, there was little or no evidence that these treatments work but could have possible harms.

Chrisp said: “When many treatments are ineffective or not well-tolerated, it is important to get an understanding of how pain is affecting a person’s life and those around them because knowing what is important to the person is the first step in developing an effective care plan.

“Importantly the draft guideline also acknowledges the need for further research across the range of possible treatment options, reflecting both the lack of evidence in this area and the need to provide further choice for people with the condition.”

 

[link url="https://www.telegraph.co.uk/news/2020/08/03/chronic-pain-should-treated-acupuncture-rather-opiates-new-guidance/?WT.mc_id=e_DM1273285&WT.tsrc=email&etype=Edi_FPM_New_ES-B&utmsource=email&utm_medium=Edi_FPM_New_ES-B20200803&utm_campaign=DM1273285"]Full report in The Daily Telegraph[/link]

 

[link url="https://edzardernst.com/2020/08/draft-guidelines-from-nice-on-treatments-for-chronic-pain-acupuncture/"]Prof Edzard Ernst on Acupuncture blog[/link]

[link url="https://www.nice.org.uk/guidance/GID-NG10069/documents/evidence-review-7"]NICE Acupuncture Evidence Review[/link]

 

[link url="https://www.theguardian.com/society/2020/aug/03/painkillers-such-as-aspirin-do-more-harm-than-good-for-chronic-pain"]Full report in The Guardian[/link]

 

[link url="https://www.nice.org.uk/guidance/GID-NG10069/documents/evidence-review-10"]NICE guidance[/link]

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