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Acupuncture for pain

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Translation - Evidence Based Acupuncture Evidence Summary-pain

Pain is a global issue. More than 1.5 billion people suffer from chronic pain[1]. Almost one third of American adults have chronic pain [2] and almost one in five surveyed Europeans report having moderate to severe chronic pain [3]. The three most common causes of chronic pain are low back pain (29%), neck pain (16%), and severe headache or migraine (15%) [4].

Pain can be acute or chronic
Acute pain warns you that you have an injury. It starts suddenly and when the injury heals, the pain stops. In acute injury, the pain is due to the pressure of inflammation in the tissues and nerves at the site of the injury. This inflammation leads to the swelling that is noticeable and is part of the body's healing response.
Chronic pain persists after the injury has healed and lasts for weeks, months, or even years. In chronic injury, nerve signals that were active during the acute injury continue to send messages to the brain that the body is in pain. Although chronic pain is not fully understood, it may be due to damaged nerves. New research suggests that chronic pain can arise from a defect in the way the brain stores sensory information [5].

Pain and Quality of Life
Almost two thirds of people with chronic pain report problems with sleeping. Lack of restorative sleep often exacerbates the pain, resulting in a frustrating cycle of pain and insomnia. Inadequate pain relief can lead to longer hospital stays, more readmissions, more outpatient visits, and reduced ability to function, which in turn leads to loss of income and reimbursements from health insurers. In addition to the financial burden that chronic pain brings, the emotional burdens for patients and families can also be significant. Chronic pain represents a huge cost for employers due to healthcare and rehabilitation expenses, as well as loss of productivity. Migraine is the third most common disease worldwide [6] and a 2015 study showed that headaches were the leading cause of lost productive time at work in the U.S. [7].

Medication is not the answer
Medications are often prescribed to treat a patient's pain in the first line. However, only 23% of patients with chronic pain found opioids effective, according to a 2006 study by the American Pain Foundation [8]. A recent study found that opioids at recommended doses were not effective for low back pain [9]. In the first randomized study examining the long-term effectiveness of opioids for pain management, those using opioids after twelve months actually had more pain than those using non-opioid pain relief [10]. 
Opioid abuse and depression have become commonplace in pain management. In the United States, prescription opioids even lead to more deaths than a heroin overdose[11]. An estimated two million people in the United States are addicted to prescription opioids, costing the economy 78.5 billion dollars per year [12].

Acupuncture for pain

Although the dangers and negative effects of prescription opioids have received the most attention in the United States, new data shows that this is a growing problem worldwide, with significant use in many European countries as well as in Australia and New Zealand [13].

Acupuncture for pain

Non-steroidal anti-inflammatory drugs (NSAIDs), the most commonly used drugs worldwide [14], are another frequently prescribed first-line treatment for pain. A recent study involving more than 440,000 patients found that the use of an NSAID, including over-the-counter medications such as Ibuprofen, even for a short period was associated with an increased risk of acute myocardial infarction, even in healthy individuals [15].  In the United Kingdom, the annual costs of treating gastrointestinal damage caused by NSAIDs in 1999 were €200 - €440 million per year. The number of patients using NSAIDs has remained constant, at approximately 7.5% of the total population [16].

  • "A cohort of 446,763 individuals was examined, including 61,460 with an acute myocardial infarction. It was found that taking a dose of NSAIDs for one week, one month, or longer than one month was associated with an increased risk of myocardial infarction... All NSAIDs, including naproxen, were found to be associated with an increased risk of acute myocardial infarction... The risk was highest during the 1st month of NSAID use and with higher dosages."  
    Bally et al 2017 [17]

Acupuncture works excellently against pain 
Acupuncture is widely known for its effectiveness in treating pain. Its unique role in reducing suffering in patients experiencing pain is one of the main reasons why it has become so popular worldwide. There is ample scientific research on the effects of acupuncture on specific painful conditions, as can be seen on the website www.evidencebasedacupuncture.org. For treating acute pain, a systematic review of 13 trials found acupuncture to be more effective than placebo acupuncture and injections with a painkiller [18].

In a very large open pragmatic scientific study regarding chronic pain, 454,920 patients were treated with acupuncture for headache, low back pain, and/or osteoarthritis. The effectiveness was assessed as clear or moderate in 76% of cases by a total of 8,727 treating acupuncturists[19]. In a two-year study in 2016, more than 89,000 patients were retrospectively surveyed, with 93% of patients reporting that their acupuncturist had been successful in treating their musculoskeletal pain [20]. A meta-analysis of 17,922 patients from randomized trials concluded that "acupuncture is effective for the treatment of chronic pain and therefore is also a reasonable referral option." Significant differences between real and placebo acupuncture suggest that acupuncture is more than a placebo [21]. A follow-up study using this data, looking at long-term pain relief, found that one of the benefits of acupuncture was that the effect lasted for twelve months after treatment had ended [22]. Another study in the journal Current Opinion in Anesthesiology is the article titled "Acupuncture for Chronic Pain: an Update and Critical Overview." The conclusion of this study is that there is increasing evidence for the effectiveness of acupuncture in the treatment of chronic low back pain, neck pain, shoulder pain, knee pain, and headache. The use of acupuncture as a complement or alternative to opioids, and in perioperative settings, has proven to be meaningful [23].

Acupuncture for pain

93% of 89,000 patients reported successful treatment for musculoskeletal pain with acupuncture
(American Specialty Health 2016) [20]

How does acupuncture work against pain?
The mechanism underlying the effectiveness of acupuncture in pain treatment has been extensively studied for over sixty years. Although there is still much to learn about acupuncture and the human body in general, the neural pathways from acupuncture point stimulation to the spinal cord and up to the pain centers in the brain have been mapped [24].

Acupuncture for pain

Figure 3 Neural Acupuncture unit: A New Concept for Interpreting Effects and Mechanisms of Acupuncture. Zhang, Z.J.et al 2012.[25]
Zoom in on image

Acupuncture has been shown to activate a number of endogenous opioids and also improve the brain's sensitivity to opioids [26].  A number of other biochemical substances involved in pain and pain reduction appear to be released or regulated by acupuncture stimulation, including ATP, adenosine, GABA, and substance P [27]. In this context, acupuncture is a safe and effective alternative with a long track record of successful use, without the side effects of pharmaceutical options for pain treatment.

References:

  • 2. Johannes C. B., Le T. K., Zhou X., Johnston J. A. & Dworkin R. H. (2010). The prevalence of chronic pain in United States adults: results of an Internet-based survey. The Journal of Pain: Official Journal of the American Pain Society, 11(11), 1230–1239.
    http://doi.org/10.1016/j.jpain.2010.07.002 (←)

  • 7. National Center for Complementary and Integrative Health (2015)
    NIH Analysis Shows Americans Are In Pain. [Online: Accessed 12 Sept 2017]
    https://www.nccih.nih.gov/news/  (←)

  • 9. Abdel Shaheed C., Maher C. G., Williams K. A., Day R. & McLachlan A. J. (2016). Efficacy, Tolerability, and Dose-Dependent Effects of Opioid Analgesics for Low Back Pain: A Systematic Review and Meta-analysis. JAMA Internal Medicine, 176(7), 958–968.
    http://doi.org/10.1001/jamainternmed.2016.1251 (←)

  • 10. Krebs EE. Effectiveness of opioid therapy vs. non-opioid medication therapy for chronic back & osteoarthritis pain over 12 months. In annual meeting, Society for General Internal Medicine, Washington DC 2017.
    https://pubmed.ncbi.nlm.nih.gov/29509867/ (←)

  • 14. Motgahre V. M., Bajait C. S. & Turankar A. (2016). Prescription pattern and adverse drug reaction profile of drugs prescribed with focus on NSAIDs for orthopedic indications at a tertiary care hospital. Skin.
    https://www.academia.edu/ (←)

  • 15. Bally M., Dendukuri N., Rich B., Nadeau L., Helin-Salmivaara A., Garbe E. & Brophy J. M. (2017). Risk of acute myocardial infarction with NSAIDs in real world use: bayesian meta-analysis of individual patient data. BMJ (Clinical Research Ed.), 357, j1909–13.
    http://doi.org/10.1136/bmj.j1909 (←)

  • 16. Cai S., Garcia Rodriguez L. A., Masso-Gonzalez E. L. & Hernandez-Diaz S. (2009). Uncomplicated peptic ulcer in the UK: trends from 1997 to 2005. Alimentary Pharmacology & Therapeutics, 30(10), 1039–1048.
    http://doi.org/10.1111/j.1365-2036.2009.04131.x (←)

  • 17. Bally M., Dendukuri N., Rich B., Nadeau L., Helin-Salmivaara
    A., Garbe E. & Brophy J. M. (2017). Risk of acute myocardial infarction with NSAIDs in real world use: bayesian meta-analysis of individual patient data. BMJ (Clinical Research Ed.), 357, j190913. 
    http://doi.org/10.1136/bmj.j1909 (←)

  • 19. Weidenhammer W., Streng A., Linde K., Hoppe A., Melchart D.
    Acupuncture for chronic pain within the research program of 10 German Health Insurance Funds–basic results from an observational study. Complementary therapies in medicine. 2007;15(4):238-46.
    https://pubmed.ncbi.nlm.nih.gov/18054725/ (←)

  • 25. Zhang Z.-J., Wang X.-M. & McAlonan G. M. (2012). Neural Acupuncture Unit: A New Concept for Interpreting Effects and Mechanisms of Acupuncture. Evidence-Based Complementary and Alternative Medicine, 2012(3), 1–23.
    http://doi.org/10.1016/j.brainresbull.2007.08.003 (←)

  • 26. Harris R. E., Zubieta J.-K., Scott D. J., Napadow V., Gracely R. H. & Clauw, D. J. (2009). Traditional Chinese acupuncture and placebo (sham) acupuncture are differentiated by their effects on μ-opioid receptors (MORs). NeuroImage, 47(3), 1077–1085. http://doi.org/10.1016/j.neuroimage.2009.05.083 (←)

Acupuncture for pain
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