30 November 2016 – Today the UK’s National Institute for Health and Care Excellence (NICE) published an update to its guidelines for the management and treatment of low back pain. Acupuncture was removed as a recommended treatment.
This decision reverses the recommendations of the 2009 committee, who recommended it on the basis of robust evidence.
Watch this short interview with Kath Berry (Acupuncture Professional) and Mel Hopper Koppelman (Acupuncture Now Foundation), who has been following the guideline developments and has some important insights that all acupuncturists should be aware of.
The guidelines govern which treatments GPs in the NHS can offer their patients suffering with back pain; removing the recommendation for acupuncture means GPs will need to rely more on treatments such as painkillers (which are less safe than acupuncture) and exercise (which is less effective).1
The reversal by this committee stands in contrast to recommendations by research and policy institutions in countries such as the United States, Canada, Germany and Australia. These increasingly include acupuncture as a safe, effective, non-pharmacological treatment for low back-pain based on evidence that shows acupuncture outperforms usual care, and has fewer risks and side effects than commonly used pain medications.
While the evidence of acupuncture’s safety and effectiveness has gotten stronger since 2009, the committee’s reversal of position was based on a new decision to focus on studies comparing acupuncture treatment to ‘sham-acupuncture’, an acupuncture-like treatment that also uses acupuncture needles but is not considered to be an inert placebo control, and is recognised to underestimate treatment effects. Guideline developers in other countries have increasingly steered away from using these sham studies, which have limited clinical relevance for GPs and their patients.
NICE found that real acupuncture outperformed the sham acupuncture controls, but the committee decided that the difference was just below the threshold to support a recommendation. Other guideline reviews, such as one published by the Agency for Healthcare Research and Quality in the United States earlier this year, found a greater difference between acupuncture and sham acupuncture control and according to their analysis, acupuncture was the most-effective non-pharmacological treatment available for low back-pain.
All other manual therapies reviewed and recommended by NICE, such as manipulation, massage or exercise, were primarily compared to usual care and generally were not shown to be better than placebo.
NICE also recommended counselling as part of a package of care, even though they did not find evidence that counselling was better than sham or usual care in their analysis.
By requiring acupuncture to outperform sham treatment, but not exercise or manual therapies for example, represents a bias in recognized guideline development practice, where great lengths are normally taken to compare treatments using the same measuring stick. NICE did not adequately justify why acupuncture alone was singled out in its analysis in this way.
The NHS spends over £300 million pounds2 treating injuries caused by NSAID use, such as GI bleeds and heart failure, resulting in two thousand preventable deaths every year in the UK3. The new guidelines do caution that doctors should recommend the lowest dose of NSAIDs for the shortest amount of time possible. Nevertheless in the UK around 2,000 deaths a year are predicted due to NSAIDS that would not occur otherwise.3
Recommending access to acupuncture as an effective drug-free alternative to treat low back pain could lead to a reduction in the intake of harmful medications.
The updated recommendations will mean reduced choice for patients and their health care providers as they could lose access to acupuncture on the NHS when it has one of the best combinations of benefit to harm ratio of any treatment evaluated by NICE, leaving providers with less effective options that potentially may carry a greater risk.
According to Professor Hugh MacPherson of the University of York, “The criteria that NICE used to evaluate acupuncture for low back pain are not the same as those used for other physical therapies, and therefore the recommendations are founded on evidence-biased medicine rather than on evidence-based medicine.”
This decision to not recommend acupuncture takes away patient choice and may well result in more serious adverse events for patients and the NHS.
1. Lewis R, FLCOM NHWPF, PhD AJS, et al. Comparative clinical effectiveness of management strategies for sciatica: systematic review and network meta-analyses. The Spine Journal. 2015;15(6):1461-1477. doi:10.1016/j.spinee.2013.08.049.
2. Moore RA, Phillips CJ. Cost of NSAID Adverse Effects to the UK National Health Service. Journal of drug assessment; 1999.
3. Tramèr MR, Moore RA, Reynolds DJ, McQuay HJ. Quantitative estimation of rare adverse events which follow a biological progression: a new model applied to chronic NSAID use. PAIN. 2000;85(1-2):169-182.