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Research on the safety of acupuncture

Research on the safety of acupuncture

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Systematic reviews of clinical studies have demonstrated the effectiveness of acupuncture [1] and expanded our knowledge of the mechanisms of action in treating numerous medical conditions. However, the benefits of each treatment must be weighed against potential drawbacks to assess its potential role in healthcare.

Reporting on adverse events in acupuncture research typically examines two aspects: serious adverse incidents such as a collapsed lung or organ puncture, and minor incidents such as bruising, fainting, or temporary worsening of symptoms. Some studies also consider feeling energized or fatigued after treatment as a minor side effect, although many practitioners and patients view this as a positive response to treatment.

In 2006, an analysis report on the safety of acupuncture was published by the British researcher Adrian White [2]. The author presented the findings of two prospective studies conducted between 1998 and 2000 in the United Kingdom. 66,229 treatments were examined. This analysis revealed that no serious side effects occurred.
In the Survey of Adverse Events Following Acupuncture (SAFA) in 2002, 2178 minor side effects were reported out of 31,822 treatments (7%). In the York Acupuncture Safety Study from 2001, which included 34,407 treatments, 4,528 (13%) minor adverse events were reported.
The differences in percentages between these two studies are, at least in part, due to varying criteria for what can be considered a side effect. In the York study, for example, feeling weak and tired after treatment was considered a side effect.
In the 2006 article, White also presents the findings of other studies describing the safety of acupuncture. The analysis included 13 studies and 4,441,103 treatments. In total, 11 serious side effects were reported. The most common serious incidents involved pneumothorax (7 per 4,441,103 treatments). There were also two incidents where a needle broke while still inserted. However, this involved the use of reusable needles rather than the disposable needles used today.
The largest source of safety data comes from the German PEP-Ac study from 2006, involving 454,920 patients and over 4 million treatments administered through the German healthcare system [3].
7.9% of patients in this study reported minor side effects, while only 0.003% (13 patients) experienced serious side effects. Minor side effects included needle pain, hematoma, and bleeding. Serious adverse effects included pneumothorax, acute hyper- or hypotensive events, a skin infection known as erysipelas, asthma attack, and exacerbation of suicidal thoughts.

Further research continues to show that acupuncture has few side effects. These studies include a prospective feasibility study published in 2017, which considered acupuncture as a 'feasible, safe, and acceptable' treatment in a Californian ICU setting without significant side effects and with a significant decrease in morphine use [4].

Systematic reviews of studies between 2013 and 2016 concluded that acupuncture, performed by trained practitioners using 'clean needle technique,' is generally a safe procedure. Medical literature also indicates that acupuncture can be successfully used in cancer patients for symptom management due to the low risks associated with its use [5] and in pregnancy-related care [6].

These clinical results make acupuncture one of the safest procedures available in contemporary medicine. When comparing this safety profile to, for example, the serious side effects of non-steroidal anti-inflammatory drugs and opioids and the number of deaths associated with their use, the safety of acupuncture becomes even clearer. There is only one caveat: acupuncture must be performed by qualified acupuncturists with adequate training.

Safety of acupuncture in context
To help patients and doctors make informed choices from treatment options, the safety of acupuncture must be evaluated and compared to the safety of available alternatives. The general evidence, including that from controlled clinical trials, shows that acupuncture, when applied by qualified practitioners, is one of the safest treatment methods compared to available alternatives.

Acupuncture is often used to reduce pain. For comparison, the safety profile of available pharmacological alternatives:

  • Of the patients prescribed opioids for pain relief, up to 25% develop a lifelong addiction [7]
  • In 2015, opioid overdoses were responsible for 33,091 deaths in the United States (more than deaths from car accidents) [8]
  • A recent study on the use of nonsteroidal anti-inflammatory drugs in 446,763 subjects shows that using any dose of NSAIDs, regardless of duration, increases the risk of a heart attack [9]

A good education is essential
According to the literature on the safety of acupuncture, a good education for acupuncturists is the essential condition to guarantee the safety of patients benefiting from this treatment method. In 2011, the prestigious journal Pain published a review of systematic reviews by Edzard Ernst and colleagues [10]. The authors examined the literature for detailed descriptions of side effects that could be attributed to acupuncture. They discussed cases that were mainly reported in developing countries, where acupuncture could be performed by untrained practitioners in conditions where hygiene rules as common in acupuncture practices in Western countries are not always followed. Such acupuncture treatments inevitably increase the risk of transmitting infectious diseases or needle injuries. However, these complications can easily be avoided by ensuring a professional education for acupuncturists and visiting acupuncture practices.

The most common side effects of acupuncture, although extremely rare, are pneumothorax, breaking of a needle in the patient's body, transmission of infectious diseases, hematoma or bleeding at the needle insertion site, no effect, worsening of symptoms, and dizziness. These adverse effects can be prevented with proper education, training in the correct techniques, and the use of reliable and sterile needles:

  • Pneumothorax or potential puncture of another structure (blood vessel, urinary bladder, pericardium) can be avoided through anatomy and physiology training and proper needle technique.
  • The use of high-quality acupuncture needles, made of stainless steel, ensuring flexibility, guarantees patient safety.
  • When (disposable) acupuncture needles are used only once and in accordance with clean needle technique guidelines, the potential transmission of infectious diseases is minimized.
  • Applying the correct techniques for needle insertion and removal prevents the occurrence of bruising.
  • Dizziness, vertigo, lack of effect, or worsening of symptoms mainly occur with incorrect diagnosis. To prevent this, acupuncturists must have sufficient knowledge of diagnosis and treatment. The World Health Organization recommends 2,500 hours of formal training as part of an accredited program.

Summary
Acupuncture is one of the safest interventions in modern medicine, with 11 serious adverse events per 4,441,103 procedures. To maintain this safety profile, acupuncture must be performed by qualified acupuncturists with demonstrable knowledge of anatomy and physiology and clean needle techniques, according to the training standards as described by the World Health Organization. Practitioners using acupuncture without adequate training increase the risk of potential side effects for their patients. Practitioners lacking skills in making the correct diagnosis may provide ineffective treatment. Despite the occurrence of some rare (serious) clinical side effects, acupuncture remains one of the safest contemporary treatments.

References

  • 2. White, A. (2006). The safety of acupuncture – evidence from the UK.2. White, A. (2006). The safety of acupuncture – evidence from the UK. Acupuncture in Medicine, 24(Suppl), 53–57. https://doi.org/10.1136/aim.24... [←]
  • 3. Linde, K., Streng, A., Hoppe, A., Jürgens, S., Weidenhammer, W., & Melchart, D. (2006). The programme for the evaluation of patient care with acupuncture (PEP-Ac) – a project sponsored by ten German social health insurance funds. Acupuncture in Medicine, 24(Suppl), 25–32. https://doi.org/10.1136/aim.24... [←]
  • 4. Feeney, C., Bruns, E., LeCompte, G., Forati, A., Chen, T., & Matecki, A. (2017). Acupuncture for Pain and Nausea in the Intensive Care Unit: A Feasibility Study in a Public Safety Net Hospital. The Journal of Alternative and Complementary Medicine, acm.2016.0323. https://doi.org/10.1089/acm.20... 
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  • 5. Lao L. Acupuncture practice, past and present: is it safe and effective?. Journal of the Society for Integrative Oncology. 2006;4(1):13. [←]
  • 6. Park, J., Sohn, Y., White, A. R., & Lee, H. (2014). The safety of acupuncture during pregnancy: a systematic review. Acupuncture in Medicine : Journal of the British Medical Acupuncture Society, 32(3), 257–266. https://doi.org/10.1136/acupme... 
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  • 7. Boscarino, J. A., Rukstalis, M., Hoffman, S. N., Han, J. J., Erlich, P. M., Gerhard, G. S., & Stewart, W. F. (2010). Risk factors for drug dependence among out-patients on opioid therapy in a large US health-care system. Addiction (Abingdon, England), 105(10), 1776–1782. https://doi.org/10.1111/j.1360... [←]
  • 8. Schuchat A, Houry D, Guy GP. New data on opioid use and prescribing in the United States. Jama. 2017 Aug 1;318(5):425-6. [←]
  • 9. 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. https://doi.org/10.1136/bmj.j1... 
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  • 10. Ernst, E., Lee, M. S., & Choi, T.-Y. (2011). Acupuncture: Does it alleviate pain and are there serious risks? A review of reviews. Pain, 152(4), 755–764. https://doi.org/10.1016/j.pain... [←]