Treatments for substance abuse - TDMaddox
TDMaddox
Accupunctureandaddiction.pdf
MJAOM | WINTER 2018 13
Acupuncture’s Role in Solving the Opioid Epidemic: Evidence, Cost-Effectiveness, and Care Availability for Acupuncture as a Primary,
Non-Pharmacologic Method for Pain Relief and
Management – White Paper 2017
Abstract The United States is facing a national opioid epidemic, and medical systems are in need of
non-pharmacologic strategies that can be employed to decrease the public’s opioid depen-
dence. Acupuncture has emerged as a powerful, evidence-based, safe, cost-effective, and
available treatment modality suitable to meeting this need. Acupuncture has been shown
to be effective for the management of numerous types of pain conditions, and mechanisms
of action for acupuncture have been described and are understandable from biomedical,
physiologic perspectives. Further, acupuncture’s cost-effectiveness can dramatically
decrease health care expenditures, both from the standpoint of treating acute pain and
through avoiding addiction to opioids that requires costly care, destroys quality of life, and
can lead to fatal overdose. Numerous federal regulatory agencies have advised or mandated
that healthcare systems and providers offer non-pharmacologic treatment options for pain.
Acupuncture stands out as the most evidence-based, immediately available choice to fulfill
these calls. Acupuncture can safely, easily, and cost-effectively be incorporated into hospital
settings as diverse as the emergency department, labor and delivery suites, and neonatal
intensive care units to treat a variety of commonly seen pain conditions. Acupuncture is
already being successfully and meaningfully utilized by the Veterans Administration and
various branches of the U.S. military, in some studies demonstrably decreasing the volume
of opioids prescribed when included in care.
Key Words: Acupuncture; opioid epidemic; pain; opiate dependency;
effectiveness; safety; cost-effectiveness; mechanism; United States
Citation: Fan AY, Miller DW, Bolash B, Bauer M, Faggert S, He H, Li YM, Matecki A,
Camardella L, Koppelman MH, Stone J, McDonald J, Meade L, Pang J. Acupuncture’s
Role in Solving the Opioid Epidemic: Evidence, Cost-Effectiveness, and Care Availability
for Acupuncture as a Primary, Non-Pharmacologic Method for Pain Relief and
Management—White Paper 2017. J Integr Med. 2017; 15(6): 411–425.
http://dx.doi.org/10.1016/S2095-4964(17)60378-9
By Arthur Yin Fan,1 David W. Miller,2,3,4 Bonnie Bolash,5
Matthew Bauer,3,5 John McDonald,6 Sarah Faggert,2,7 Hongjian He,2,8,9 Yong Ming Li,10 Amy Matecki,9,11 Lindy Camardella,2,3 Mel Hopper Koppelman,3,6 Jennifer A.M. Stone,2,12 Lindsay Meade,2,3 John Pang13
1. The American TCM Association, Vienna, VA 22182, USA
2. The American Society of Acupuncturists, Chicago, IL 60618, USA
3. The Joint Acupuncture Opioid Task Force, La Verne, CA 91750, USA
4. Pacific College of Oriental Medicine, Chicago, IL 60601, USA
5. The Acupuncture Now Foundation, La Verne, CA 91750, USA
6. The Acupuncture Evidence Project, Providence, RI 02860, USA
7. The Acupuncture Society of Virginia, Vienna, VA 22182, USA
8. The National Federation of Chinese TCM Organizations, New York, NY 11501, USA
9. The American Alliance for Professional Acupuncture Safety, Greenwich, CT 06878, USA
10. The American Traditional Chinese Medicine Society, New York, NY 11501, USA
11. Highland Hospital, Alameda Health System, Oakland, CA 94602, USA
12. Indiana University School of Medicine, Indianapolis, IN 46202, USA
13. University of California, San Diego School of Medicine, San Diego, CA 92093, USA
14 MERIDIANS: The Journal of Acupuncture and Oriental Medicine | WINTER 2018
ACUPUNCTURE’S ROLE IN SOLVING THE OPIOID EPIDEMIC – WHITE PAPER 2017
Received October 8, 2017; accepted October 17, 2017.
Correspondence: David W. Miller, MD, FAAP, LAc, Dipl OM
(NCCAOM); E-mail: [email protected]
This white paper was co-sponsored by the American Society
of Acupuncturists (ASA), the American Alliance for Professional
Acupuncture Safety (AAPAS), the Acupuncture Now Foundation
(ANF), the American TCM Association (ATCMA), the American TCM
Society (ATCMS), and the National Federation of Chinese TCM
Organizations (NFCTCMO). This article has been simultaneously
published by the Journal of Integrative Medicine, November
2017, V. 15, #6, pp. 411-425.
1. Introduction
In 2015 it was estimated that 25.3 million Americans suffered
from chronic pain, while an estimated 126 million American
adults reported some type of pain in the prior three months.1 As a
result, more than 240 million prescriptions were written for opioid
medications during that year.2 An unfortunate consequence of
this high use and availability of opioids, is a growing number of
opioid-related deaths from addiction and overdose.
More than 33,000 Americans died from opioid drugs in 2015,
and more than 64,000 died in 2016.3 Due to the severity of this
epidemic, a White House panel urged the United States (U.S.) pres-
ident to declare the opioid crisis a national emergency. August 31,
2017 was designated as “International Overdose Awareness Day”
by the Centers for Disease Control and Prevention (CDC).4
To cope with the opioid crisis, various federal regulatory and over-
sight agencies, including the U.S. Food and Drug Administration
(FDA), the National Academies of Sciences, Engineering, and
Medicine (NASEM), and the Joint Commission have started
to advise or mandate that healthcare systems and providers
offer non-pharmacologic treatment options for pain control.5-7
Acupuncture stands as the most evidence-based, immediately
available choice to fulfil these calls.
The aim of this white paper is to summarize for academic scholars,
healthcare professionals, administrators, policymakers, and the
general public the available evidence for acupuncture as a treat-
ment for various pain conditions as well as for opiate dependency.
This includes evidence on the safety, cost-effectiveness, mecha-
nisms of action, and provider availability for acupuncture.
2. Acupuncture is an effective, safe, and cost-effective treatment for numerous types of acute and chronic pain; acupunc- ture should be recommended as a first line treatment for pain before opiates are prescribed, and may reduce opioid use
2.1 Effectiveness/Efficacy of acupuncture for different types of pain
There is growing research evidence to support the effectiveness
and efficacy of acupuncture for the relief of numerous types of
pain, especially chronic pain, as well as for the use of acupuncture
for a diverse array of medical conditions. In an independently
published work, which is the largest and most comprehensive
of its kind for the period evaluated, McDonald and Janz8 sum-
marized the research from March 2013 to September 2016 for
acupuncture, published and available in all languages on PubMed
and in the Cochrane Library. They looked at systematic reviews,
meta-analyses, network meta-analyses, overviews of systematic
reviews (NHMRC level I evidence), and a number of narrative
reviews. They performed meta-analyses on 62 of the non-Co-
chrane systematic reviews, representing pooled data from more
than 1,000 randomized controlled trials (RCTs). They assessed
and graded the quality of evidence, and noted the strength of
evidence for acupuncture for numerous conditions (Box 1).
Acupuncture has been found to be effective for treating various
types of pain, with the strongest evidence emerging for back pain,
neck pain, shoulder pain, chronic headache, and osteoarthritis. In
an individual patient meta-analysis of 17,922 people from 29 RCTs,
patients receiving acupuncture had less pain, with scores that
were 0.23 (95% confidence interval (CI), 0.13–0.33), 0.16 (95% CI,
0.07–0.25), and 0.15 (95% CI, 0.07–0.24) standard deviations (SDs)
lower than sham controls for back and neck pain, osteoarthritis,
and chronic headache, respectively; the effect sizes in comparison
to non-acupuncture controls were 0.55 (95% CI, 0.51–0.58), 0.57
(95% CI, 0.50–0.64), and 0.42 (95% CI, 0.37–0.46) SDs. A variety
of pain severity and disability scores were used, including Visual
Analog Scale ( VAS) ratings, the Western Ontario and McMaster
Universities Osteoarthritis Index ( WOMAC), and the Roland Morris
Disability Questionnaire. These results were robust to a variety of
sensitivity analyses, including those related to publication bias.9
“ Acupuncture has been shown to be effective for the management of numerous types of pain conditions, and mechanisms of action for acupuncture have been described and are understandable from biomedical, physiologic perspectives.”
MJAOM | WINTER 2018 15
In the largest study of its kind to date, 454,920 patients were
treated with acupuncture for headache, low-back pain, and/or
osteoarthritis in an open pragmatic trial. Effectiveness was rated
by the 8,727 treating physicians as marked or moderate in
76% of cases.10
In a network meta-analysis comparing different physical interven-
tions for pain from knee osteoarthritis, acupuncture was found
to be superior to sham acupuncture, muscle-strengthening
exercise, tai chi, weight loss, standard care, and aerobic exercise
(in ranked order). Acupuncture was found to be more effective
than muscle-strengthening exercises, with a statistically significant
difference = 0.49, 95% CI [0.00–0.98].11
In early 2017, the American College of Physicians (ACP) published
guidelines based on the evidence for the non-invasive treatment
of low-back pain. For acute or subacute low-back pain, the ACP
recommends non-pharmacologic treatment with acupuncture,
PERSPECTIVES
Box 1. Acupuncture for the Use of Numerous Conditions Including Pain Conditions: the Acupuncture Evidence Project (Mar 2013–Sept 2016)
- Modulating sensory perception thresholds
- Neck pain (some types/non-whiplash)
- Obesity
- Peri-menopausal & post-menopausal insomnia
- Plantar heel pain
- Post-stroke insomnia
- Post-stroke shoulder pain
- Post-stroke spasticity
- Post-traumatic stress disorder
- Prostatitis pain/chronic pelvic pain syndrome
- Recovery after colorectal cancer resection
- Restless leg syndrome
- Schizophrenia (with antipsychotics)
- Sciatica
- Shoulder impingement syndrome (early stage) (with
exercise)
- Shoulder pain
- Smoking cessation (up to 3 months)
- Stroke rehabilitation
- Temporomandibular joint disorder
Evidence of Positive Effect
- Allergic rhinitis (perennial & seasonal)
- Chemotherapy-induced nausea and vomiting
(with anti-emetics)
- Chronic low-back pain
- Headache (tension-type and chronic)
- Knee osteoarthritis
- Migraine prophylaxis
- Post-operative nausea & vomiting
- Post-operative pain
Evidence of Potential Positive Effect
- Acute low-back pain
- Acute stroke
- Ambulatory anaesthesia
- Anxiety
- Aromatase inhibitor-induced arthralgia
- Asthma in adults
- Back or pelvic pain during pregnancy
- Cancer pain
- Cancer-related fatigue
- Constipation
- Craniotomy anaesthesia
- Depression (with antidepressants)
- Dry eye
- Hypertension (with medication)
- Insomnia
- Irritable bowel syndrome
- Labor pain
- Lateral elbow pain
- Menopausal hot flashes
16 MERIDIANS: The Journal of Acupuncture and Oriental Medicine | WINTER 2018
along with superficial heat, massage, or spinal manipulation, and
nonsteroidal anti-inflammatory drugs or skeletal muscle relaxants.
For chronic low-back pain, the ACP also recommends acupuncture,
in addition to exercise, multidisciplinary rehabilitation, mindful-
ness-based stress reduction, tai chi, yoga, motor control exercise,
progressive relaxation, electromyography biofeedback, low-level
laser therapy, operant therapy, cognitive behavioral therapy, and
spinal manipulation, etc.12
A systematic review and meta-analysis on acupuncture for the
treatment of sciatica reported that acupuncture was superior to
standard pharmaceutical care (such as ibuprofen, diclofenac, and
prednisone) in reducing pain intensity (mean difference (MD) =
1.25, 95% CI [1.63–0.86]) and pain threshold (MD = 1.08, 95% CI
[0.98–1.17]). Effectiveness, pain intensity, and pain threshold scales
were used.13
A systematic review and network meta-analyses of 21 different inter-
ventions for sciatica found that acupuncture was second in global
effect only to biological agents. It was found to be superior to all
other interventions including non-opioid and opioid medications.14
A systematic review on acupuncture and moxibustion for lateral
elbow pain found moderate-level evidence that acupuncture and
moxibustion were more effective than sham. It also found low-level
evidence that acupuncture and moxibustion may be superior or
equal to standard care.15 A systematic review on acupuncture for
plantar heel pain found that evidence supporting the effectiveness
of acupuncture was comparable to the evidence available for
standard care interventions such as stretching, night splints, and
dexamethasone.16
The use of acupuncture to relieve pain associated with surgical
procedures captured the world’s attention in the early 1970s.
When in China, well-known New York Times journalist James Reston
witnessed acupuncture’s effectiveness on his post-operative pain.
He published his personal experience with acupuncture shortly
before President Richard Nixon’s trip to China.
Since then, reports in the scientific literature reveal that acupunc-
ture has been used before, during, and after surgery to manage pain
and to improve post-surgical recovery in a variety of contexts.17-25 It
is noteworthy to mention that acupuncture has been reported to
be effective in pain relief during and after surgical procedures on
children and animals as well.19,20,26,27
Nonetheless, over the past two decades in the U.S., post-operative
pain management has come to rely increasingly on opioids, while
underutilizing alternative analgesics such as acupuncture. In 2012,
surgeons and dentists combined prescribed 16.2% of all opioids in
the U.S., trailing only family practices as the leading source of opioid
prescriptions at 18.2%.28 Eighty to ninety-four percent of patients
undergoing low-risk surgical procedures fill a prescription for
opioids within seven days.29,30
Recent data has shown that opioid prescriptions vary widely and
that the majority of surgical patients are over-prescribed opi-
oids—approximately 70% of pills go unused.31 The risk of chronic
opioid use after surgery in previously non-dependent patients
is determined to be 5.9%–6.5%,32 although in select populations
such as head and neck cancer patients, the risk is up to 40%.33 The
increase in post-operative opioid use is somewhat paradoxical
considering that known adverse effects such as sedation, pneu-
monia,34,35 ileus, urinary retention, and delirium prolong patient
recovery and delay the meeting of discharge goals.36
Acupuncture has emerged as a promising adjunctive analgesic
modality to reduce the risk of post-operative opioid dependence.
A meta-analysis published in late 2017 in JAMA Surgery focused on
non-pharmacological treatments in reducing pain after total knee
arthroplasty. Thirty-nine RCTs were included in the meta-analysis
(2,391 patients). Moderate-certainty level evidence showed that
electrotherapy reduced the use of opioids (MD = −3.50; 95% CI,
[−5.90 to −1.10] morphine equivalents in milligrams per kilogram
per 48 hours; P = 0.004; I2 = 17%), and that acupuncture delayed
opioid use (MD = 46.17; 95% CI, [20.84–71.50] minutes to the
first patient-controlled analgesia; P < 0.001; I2 = 19%). There was
low-certainty level evidence that acupuncture improved pain
(MD = 1.14; 95% CI, [1.90–0.38] on a VAS at 2 days; P = 0.003; I2 = 0%).
Evidence showed that acupuncture out-performed cryotherapy,
continuous passive motion, and preoperative exercise in the stud-
ied condition.37 Reduction in opioid use has been demonstrated
across a wide range of both minor and major surgical procedures,
including cardiac surgery,38 thoracic surgery,39 and craniotomy.17,40
Additionally, it was reported that acupuncture may even reduce
post-operative ileus and expedite bowel recovery after colorectal
cancer resection.41 Acupuncture is often combined with electric
stimulation, and electro-acupuncture may have added clinical
benefit in post-operative pain management.
A Cochrane systematic review on acupuncture or acupressure
for primary dysmenorrhea found that both acupuncture and
acupressure were more effective in reducing pain than placebo
controls.42 Five other systematic reviews and/or meta-analyses
on various forms of acupoint stimulation including acupuncture,
acupressure, and moxibustion for primary dysmenorrhea have
reported similar outcomes.43-47
The effectiveness of acupuncture for labor pain is still unclear,
largely due to the heterogeneity of designs and methods in
studies, which have produced mixed results. While some studies
reported no reduction in analgesic medications, some studies
reported reduction of pain during labor, reduced use of opioid
medications and epidural analgesia, and a shorter second stage
of labor.48-50
ACUPUNCTURE’S ROLE IN SOLVING THE OPIOID EPIDEMIC – WHITE PAPER 2017
MJAOM | WINTER 2018 17
A systematic review of acupuncture for trigeminal neuralgia
suggests that acupuncture may be equal to or superior to
carbamazepine. However, the evidence is weakened by the low
methodological quality of some included studies.51
A Cochrane systematic review on acupuncture for fibromyalgia
found low-to-moderate certainty level evidence that acupuncture
improves pain and stiffness compared with no treatment and
standard therapy. Furthermore, electro-acupuncture is likely better
than manual acupuncture for pain in fibromyalgia, although more
studies with methodological rigor are warranted.52
A prospective, randomized trial of acupuncture vs. morphine
to treat emergency department/emergency room patients
with acute onset, moderate to severe pain was conducted.
Acupuncture provided more effective and faster analgesia than
morphine and was better tolerated. The study included 300
patients, with 150 patients in each group. Success rate was signifi-
cantly different between the two groups (92% in the acupuncture
group vs. 78% in the morphine group, P < 0.001).
Resolution time was (16 ± 8) minutes in the acupuncture group
vs (28 ± 14) minutes in the morphine group (P < 0.005). Overall, 89
patients (29.6%) experienced minor adverse effects; of these, 85
(56.6%) were in the morphine group and only 4 (2.6%) were in the
acupuncture group (P < 0.001).53
The above-mentioned meta-analysis included 29 trials and 17,922
patients with chronic pain conditions; data on longer-term follow
up (available for 20 trials, including 6,376 patients) suggests
that approximately 90% of the benefit of acupuncture relative
to controls would be sustained at 12 months post-treatment.
Patients can generally be reassured that treatment effects persist
for some duration.54
2.2 Safety and feasibility of acupuncture for pain
management
Strong evidence for the safety of acupuncture in chronic pain
management comes from an open pragmatic trial involving
454,920 patients who were treated for headache, low-back pain,
and/or osteoarthritis. Minor adverse events were reported in 7.9%
of patients while only 0.003% (13 patients) experienced severe
adverse events. Minor adverse events included needling pain,
hematoma, and bleeding, while serious adverse events included
pneumothorax, acute hyper- or hypotensive crisis, erysipelas,
asthma attack, and aggravation of suicidal thoughts.10
In a prospective feasibility study, acupuncture was seen as
feasible, safe, and acceptable in an intensive care unit setting by
patients from diverse backgrounds.55 A systematic review suggests
that acupuncture performed by trained practitioners using clean
needle technique is a generally safe procedure.56 The medical
literature also indicates that acupuncture may be used success-
fully on cancer patients for symptom management due to the low
risks associated with its use.57
2.3 Cost-effectiveness of acupuncture for pain management
A systematic review of eight cost-utility and cost-effectiveness
studies of acupuncture for chronic pain indicated that the cost
per quality-adjusted life-year gained was below the thresholds
used by the UK National Institute for Health and Clinical
Excellence for “willingness to pay.” The chronic pain conditions
discussed in the systematic review included low-back pain, neck
pain, dysmenorrhoea, migraine and headache, and osteoarthritis.58
A cost-effectiveness analysis of non-pharmacological treatments
for osteoarthritis of the knee found acupuncture to be the most
cost-effective option when analysis was limited to high-quality
studies.59 Using acupuncture for pain management, patients and
insurers can save money and successfully manage their pain
and other symptoms without the adverse risks associated with
prescription medications.
A recent study from the Center for Health Information and
Analysis, in response to a piece of Massachusetts legislation
seeking mandated coverage for acupuncture for some conditions,
found that full insurance coverage for acupuncture would
increase an average insured member’s monthly health insurance
premium only by $0.38 to $0.76. Acupuncture was noted to save
$35,480, $32,000, $9 000, and $4,246 per patient for migraine,
angina pectoris, severe osteoarthritis, and carpal tunnel syndrome
respectively.60 Compared to the large fees associated with
imaging, prescription medications and surgery for pain conditions,
acupuncture proved extremely cost-effective.
The Acupuncture Evidence Project also enumerates those
conditions for which they found evidence of acupuncture being
cost-effective (Box 2).61
PERSPECTIVES
Box 2. Conditions with Demonstrated Evidence of Cost-Effectiveness
- Allergic rhinitis
- Low-back pain
- Ambulatory anaesthesia
- Migraine
- Chronic pain: neck pain (plus usual medical care)
- Depression
- Osteoarthritis
- Dysmenorrhoea
- Post-operative nausea and vomiting
- Headache
18 MERIDIANS: The Journal of Acupuncture and Oriental Medicine | WINTER 2018
A 2015 study by Da Silva62 published in the journal Headache
showed acupuncture to be at least as effective as conventional
drug preventative therapy for migraine and to be safe, long-
lasting, and cost-effective. Another 2015 study by Liodden and
Norheim63 noted acupuncture to be potentially useful for post-op-
erative pain and post-operative nausea and vomiting, and to be a
low-cost intervention. A 2014 study by Spackman et al.64 showed
acupuncture to be cost-effective compared to counselling or
usual care alone.
Two studies demonstrated acupuncture’s cost-effectiveness for
the treatment of low-back pain. A study by Taylor et al.65 from
2014 showed that acupuncture as a complement to standard care
for the relief of chronic low-back pain was highly cost-effective,
costing around $48,562 per disability-adjusted life-year (DALY )
avoided. It also found that when comorbid depression was
alleviated at the same rate as pain, the cost was around $18,960
per DALY avoided. A study by Andronis et al.66 also identified
acupuncture as likely to be cost-effective for low-back pain.
2.4 Can adjunctive acupuncture treatment reduce the use
of opioid-like medications?
Some studies have reported reduced consumption of opioid-like
medication (OLM) by more than 60% following surgery when
acupuncture is used.67,68 A pilot RCT also showed a reduction by
39% in OLM use in non-malignant pain after acupuncture, an
effect which lasted fewer than eight weeks after acupuncture
treatment ceased.69 The above mentioned meta-analysis, having
moderate-certainty level evidence, showed that electro-acu-
puncture therapy reduced the use of opioids, and acupuncture
delayed opioid use, with low-certainty level evidence indicating
that acupuncture improved pain.37 The conclusions suggest that
electro-acupuncture may be effective in reducing or delaying the
use of opioid medications.
In a study examining acupuncture’s effectiveness in treating
pain in a military cohort of 172 at a U.S. Air Force medical center,
acupuncture dramatically decreased the use of opiates and
other pain medications among personnel. Opioid prescriptions
decreased by 45%, muscle relaxants by 34%, non-steroidal
anti-inflammatory drugs by 42%, and benzodiazepines by 14%.
Quality of life measures also showed impressive changes, with
some measures of improvements showing statistical significance
(P < 0.001).70
The Veterans Administration is increasingly looking to incorporate
acupuncture into care, as is the U.S. Air Force and other military
branches. Training of military physicians is increasing, and systems
are being studied to further incorporate acupuncture. The military
is rapidly incorporating this care into its offered services for
service members.71,72
Studies of the effects of opioid analgesia in the elderly reveal a
significant burden of disease due to falls from mental impairment.
This is worsened when seniors are using multiple medications
affecting cognition. In a recent study, serious falls as per Medicare
Part A and B ICD/CPT codes were evaluated in 5,556 nursing home
residents aged 65 or greater. Seniors taking > 3+ central nervous
system (CNS) standardized daily doses were more likely to have a
serious fall than those not taking any CNS medications (adjusted
odds ratio = 1.83, 95% CI [1.35–2.48]), and the authors urge,
“Clinicians should be vigilant for opportunities to discontinue or
decrease the doses of individual CNS medications and/or consider
non-pharmacological alternatives.”73
A recent study in the New Zealand Medical Journal noted that
medication-related harms were both common and created a
substantial burden of disease for patients and the healthcare
system. They listed opioids first among the six categories of
medications causing the most significant burden.74 In light of the
findings of these studies and similar, utilization of non-pharmaco-
logic treatment options such as acupuncture must be a priority of
paramount status.
3. Acupuncture’s analgesic mechanisms have been extensively researched and acu- puncture can increase the production and release of endogenous opioids in animals and humans
Mechanisms underlying acupuncture’s analgesic effects have
been extensively researched for over 60 years. In animal models,
acupuncture and/or electro-acupuncture has been shown to
be effective for the alleviation of inflammatory, neuropathic,
cancer-related, and visceral pain. Mechano-transduction of the
needling stimulus at specific points on the body triggers the
release of ATP and adenosine, which bind to local afferents.75,76
Ascending neural pathways involving Aβ, Aδ, and C sensory fibers have been mapped (using techniques such as single fiber
recordings with Evans blue dye extravasation), as have been a
mesolimbic analgesic loop in the brain and brainstem, descending
pathway mechanisms, dopaminergic contributors, and cytokine,
glutamate, nitric oxide, and gamma-amino butyric acid
(GABA) effects.
Acupuncture analgesia has been shown to involve several classes
of opioid neuropeptides including enkephalins, endorphins,
dynorphins, endomorphins, and nociceptin (also known as
orphanin FQ). Among the non-opioid neuropeptides, substance P,
vasoactive intestinal peptide, and calcitonin gene-related peptide
have been investigated for their roles in both the analgesic and
anti-inflammatory effects of acupuncture.77-80
ACUPUNCTURE’S ROLE IN SOLVING THE OPIOID EPIDEMIC – WHITE PAPER 2017
MJAOM | WINTER 2018 19
Given that acupuncture analgesia activates the production and
release of endogenous opioids and activates μ and δ opioid receptors, it is feasible that acupuncture used in conjunction with
OLM might alleviate pain with a lower OLM dose for patients
already taking OLM.81 This idea is further supported by evidence
that acupuncture increases μ opioid receptor binding potential,
allowing for effective analgesia at lower doses of OLM.82
For patients not yet prescribed OLM, acupuncture should be
recommended prior to OLM prescription commencing. This would
be in-line with existing guidelines, such as those by the ACP12 and
the CDC,83 which recommend that safe and effective non-opioid
alternatives should first be exhausted before resorting to OLM.
It is important to note as well that opioids as a monotherapy are
often not as successful as may be thought in the general public
perception. A recent systematic review of opioid analgesics for
low-back pain, which included 7,925 participants, found that
opioids were poorly tolerated and for those who tolerate them
the effect is unlikely to be clinically important within guideline
recommended doses.84
The first ever RCT evaluating the long-term effectiveness of
opioids, found that those on long-term opioid analgesia were
actually in marginally more pain at 12 months than those in the
non-opioid group.85 Hence, complementary methods of pain
control are critical to successful patient management.
4. Acupuncture is effective for the treat- ment of chronic pain involving maladaptive neuroplasticity
Adverse neuroplastic changes can present a challenge in pain
management, as maladaptive neuroplasticity can be associated
with severe chronic pain that is resistant to treatment. Via
peripheral stimulation, acupuncture may relieve the symptoms
of patients affected by problematic neuroplastic changes. There
is evidence that acupuncture has the capacity to reverse adverse
neuroplastic changes in the dorsal horns of the spine, as well as in
the somatosensory cortex.86-89 This suggests that acupuncture may
have an important role in treating chronic pain which involves
adverse neuroplastic changes.
5. Acupuncture is a very promising, already utilized adjunctive therapy in opiate depen- dency and rehabilitation
In 1973, Wen et al.90 from Hong Kong published an accidental
finding that ear acupuncture treatment for respiratory patients
had apparently alleviated opioid withdrawal signs and symptoms.
These findings were replicated by others around the world,
including in New York and Sydney in the mid-1970s.
In 1985, Dr. Michael Smith and colleagues in New York established
the National Acupuncture Detoxification Association (NADA),
which today operates in over 40 countries with an estimated
25,000 providers. There are more than 1,000 programs in the U.S.
and Canada that now use acupuncture to help addicts overcome
their addictions.91
Evidence for acupuncture’s role in addiction treatment has been
found in both animal and human studies. In 2009, Hu et al.92 found
that electro-acupuncture in rats appeared to affect dopamine
neurons in the ventral tegmental area, meaningfully improving
the deleterious effects caused to this area by opioid medication.
In 2012, Lee et al.93 demonstrated that electro-acupuncture could
be used to decrease drug-seeking behaviour in rats. As far back as
1978 it was demonstrated that acupuncture decreased biochem-
ical markers of stress in heroin addicts compared to observational
controls.94
In 2014, Chan et al.95 demonstrated that acupuncture decreased
the amount of morphine used by addicts in treatment and
simultaneously improved sleep in the treatment subjects.
Acupuncture for addiction is a versatile modality that can be
effortlessly integrated into many environments including prisons,
in- and outpatient programs, community centers, disaster relief,
and humanitarian aid efforts. Furthermore, acupuncture addiction
protocols can address acute and prolonged withdrawal symp-
toms, stress and anxiety related to drug withdrawal, and help
prevent relapse. Using drugs to treat those already drug-addicted
is not a rational plan of action, and finding sound, non-pharmaco-
logic treatment options is of paramount importance.
A meta-analysis done in 2012 concluded that “the majority [of
studies] agreed on the efficacy of acupuncture as a strategy for
the treatment of opiate addiction” and that “neurochemical and
behavioral evidence has shown that acupuncture helps reduce
the effects of positive and negative reinforcement involved in
opiate addiction by modulating mesolimbic dopamine neurons.
Moreover, several brain neurotransmitter systems involving
opioids and GABA have been implicated in the modulation of
dopamine release by acupuncture.”96
In a recent RCT involving 28 newborns with neonatal abstinence
syndrome, laser acupuncture plus OLM significantly reduced
the duration of oral morphine therapy when compared to OLM
alone.97 The mechanism for acupuncture in opiate withdrawal
was found to be mediated by the endogenous opioid “dynorphin”
binding to κ opioid receptors.98 While considerable research on acupuncture’s role in addiction is still greatly needed,
long-standing and new data provide a sound foundation for
that future research. Demonstration of trans-species effects with
PERSPECTIVES
20 MERIDIANS: The Journal of Acupuncture and Oriental Medicine | WINTER 2018
multiple, plausible mechanisms and documented clinical efficacy
in humans for opioid addiction specifically, coupled with vast,
existing clinical precedent of use in this realm, argues strongly for
acupuncture’s likely value in this domain.
6. Acupuncture has been recommended as a first-line, non-pharmacologic therapy by the FDA as well as the NASEM in coping with the opioid crisis; the Joint Commission has also mandated that hospitals provide non-pharmacologic pain treatment modalities
In early May 2017, the U.S. FDA released proposed changes to its
opioid prescription guidelines. Entitled a “Blueprint for Prescriber
Education for Extended-Release and Long-Acting Opioids,” the
guidelines now recommend that doctors become informed about
non-pharmacologic options for pain control to help avoid the
overuse of opioids.5 Per the FDA’s request, the NASEM released a
report to outline the state of the science regarding prescription
opioid abuse and misuse as well as the evolving role that opioids
play in pain management.
The new NASEM report on pain management and opioids
recommends more public education, reimbursement models, and
support for non-drug approaches to pain treatment. It systemati-
cally summarizes the evidence for acupuncture’s clinical benefits
in treating different pain conditions, and provides an overview of
some of the basic science underlying acupuncture’s mechanisms
in pain management.6
In addition, effective January 1, 2018, the Joint Commission
has mandated that hospitals provide non-pharmacologic pain
treatment modalities.7 Acupuncture is ideally suited to fulfil this
mandate. These official, evidence-based clinical guidelines are in
line with global healthcare trends. As of November 2015, acupunc-
ture had over 870 recommendations in official clinical guidelines
for over 100 conditions from institutions in over 30 countries.99
7. Among the most commonly recommended, non-pharmacological man- agement options for pain relief, evidence supports acupuncture as the most specific and effective for opioid abuse and overuse
Several forms of non-pharmacological management options for
acute and chronic pain have been examined, including physical
therapy, spinal cord manipulation, yoga, tai chi, cognitive behav-
ioral therapy, as well as others. Among those therapies commonly
recommended by medical authorities, evidence supports
acupuncture as the most specific in targeting the endogenous
opioid system. There is more evidence that acupuncture can
induce endorphins to cope with acute and chronic pain in basic
research than for any other non-pharmacological approach for
pain.12,37,53,60 Other mechanisms for acupuncture’s effects have also
been discussed above.
8. Acupuncture is widely available from qualified practitioners nationally
In 2013, more than 28,000 licensed acupuncturists were estimated
to be practicing in the U.S., with many more in training.100 A 2015
study found the number of trained licensed acupuncturist prac-
titioners to be approximately 34,400. This number was noted to
have increased by 23.3% and 52.1% compared to the years 2009
(n = 27 965) and 2004 (n = 22 671) respectively, increasing about
1,266 per year.101 Currently, the Council of Colleges of Acupuncture
and Oriental Medicine has 57 schools in its membership,102 with
approximately ten schools offering doctoral degrees.
The National Certification Council for Acupuncture and Oriental
Medicine has certified more than 18,000 practitioners for minimal
competency.103 The practitioners emerging from this educational
and testing infrastructure are the most highly trained in Chinese
medicine as a complete system, and the training capacity is vastly
underutilized. This system could produce many more practitioners
were demand increased.
The American Academy of Medical Acupuncture also represents
more than 1,300 medical doctors trained to offer acupuncture
services and has approved nine programs for medical doctor
certification in acupuncture.104 One certification program alone
has trained more than 6,000 physicians in medical acupuncture,105
so a conservative estimate of the total number of physicians
trained would be approximately 10,000, though the number
actively practicing acupuncture is unknown.
Most states allow physicians to practice acupuncture, with some
specifying additional training.106 Increased coverage and demand
for acupuncture will lead to a greater supply of providers as well.
As noted above, NADA providers are estimated at 25,000 individu-
als, with more than 1,000 programs in the U.S. and Canada.
ACUPUNCTURE’S ROLE IN SOLVING THE OPIOID EPIDEMIC – WHITE PAPER 2017
MJAOM | WINTER 2018 21
PERSPECTIVES
Appendix 1. Effectiveness of Acupuncture
Author, Year Topic/Intervention Participants/Population Primary Outcomes Key Findings Study Quality
Vickers et al., 20129
Acupuncture versus sham acupuncture and non-acupuncture in back, neck and shoulder pain, chronic headache, and osteoarthritis
Systematic review of 31 RCTs (17,922 subjects) and meta-analysis of individual patient data from 29 of these 31 RCTs in back, neck and shoulder pain; chronic headache; osteoarthritis
A variety of pain severity and disability scores such as VAS, WOMAC, Roland Morris Disability Questionnaire
Acupuncture was superior to sham acupuncture and non-acupuncture for each pain condition
High-quality evidence
Weidenhammer et al., 200710
Acupuncture for headache, low-back pain, and osteoarthritis
Open pragmatic trial of 454,920 subjects with headache, low-back pain, and osteoarthritis
Treating physician rating of “marked, moderate, minimal or poor improvement (which included no improvement and worse)”
Physician ratings: 22% marked, 54% moderate, 16% minimal and 4% poor improvement
Low-quality evidence— open pragmatic trial with no blinding and no external assessors
Corbett et al., 201311
Comparison of 22 physical therapies for knee osteoarthritis pain
Review of 152 trials and network meta-analysis of 12 RCTs with low risk of bias comparing 22 physical therapies in knee osteoarthritis pain
Knee pain
Acupuncture was equal to balneotherapy and superior to sham acupuncture, mus- cle-strengthening exercise, Tai Chi, weight loss, standard care and aerobic exercise (in ranked order)
110 of 152 studies analysed were of poor quality. Network meta-analysis included 12 RCTs with low risk of bias
Ji et al., 201513 Acupuncture versus standard pharmaceutical care in sciatica
Systematic review and meta-analysis of 12 RCTs in sciatica
Effectiveness, pain intensity, and pain threshold
Acupuncture was superior to standard pharmaceutical care in effectiveness, reducing pain intensity and pain threshold
Low-to-moderate quality evidence
Lewis et al., 201514
Comparison of 21 different interventions for sciatica
Systematic review and network meta-analyses of 122 studies including 90 randomized or quasi-ran- domized controlled trials comparing 21 different interventions for sciatica
Global effect, and pain intensity
In global effect and reduction in pain intensity, acupuncture was second only to biological agents (cytokine-modulating drugs), and superior to all other interventions tested including non-opioid and opioid medications
9% of studies had a strong overall quality rating; 7% of studies had a strong overall external validity rating; 21% of studies used both adequate randomization and adequate or partially adequate allocation concealment
Gadau et al., 201415
Acupuncture and/or moxibustion versus sham acupuncture, another form of acupuncture, or conventional treatment in lateral elbow pain
Systematic review of 19 RCTs
Pain, and grip strength
Acupuncture is more effective than sham acupuncture (moder- ate-quality studies); acupuncture or moxibustion is more effective than conventional treatment (low-quality studies)
Low-to-moderate quality evidence
Cho et al., 201520
Real versus sham acupuncture in acute post-operative pain after back surgery
Systematic review and meta-analysis of 5 trials
24-hour post-opera- tive pain intensity on VAS; 24-hour opiate demands
Real acupuncture was superior to sham in reducing pain intensity but not opiate demand at 24 hours
3 of 5 trials were high quality
Levett et al., 201448
Acupuncture, standard care, sham acupuncture, acupressure and mixed controls in various combi- nations in labor pain
A critical narrative review of 4 systematic reviews in labor pain
Pain intensity, analgesic use, and length of labor
Acupuncture reduces pain intensity, analgesic use and length of labor
Conflicting evidence
22 MERIDIANS: The Journal of Acupuncture and Oriental Medicine | WINTER 2018
Author, Year Topic/Intervention Participants/Population Primary Outcomes Key Findings Study Quality
Clark et al., 201216
Acupuncture versus various comparators including standard care, sham acupuncture and other forms of acupunc- ture in plantar heel pain
Systematic review of 5 RCTs and 3 non-random- ized comparative trials
Various pain and disability scales (morning pain, walking pain, and tenderness)
Acupuncture for plantar heel pain is supported by evidence which is equivalent to evidence supporting standard care (stretching, splints, and dexamethasone)
Evidence at levels I and II supporting the effec- tiveness of acupuncture for heel pain, leading to a recommendation at Grade B
Deare et al., 201352
Manual and electro-acu- puncture compared with sham acupuncture, standard therapy and no treatment in fibromyalgia
Cochrane systematic review of 9 RCTs in fibromyalgia
Pain, stiffness, sleep, fatigue and global wellbeing
Acupuncture improves pain and stiffness compared to standard therapy and no treatment, but not compared to sham acupuncture
Low-to-moderate quality evidence
Smith et al., 201142
Acupuncture or acupressure versus placebo control, usual care or pharmacological treatment in primary dysmenorrhea
Cochrane systematic review of 10 RCTs (944 subjects) on acupuncture (6) or acupressure (4) for primary dysmenorrhea
Pain relief, analgesic use, quality of life, improvement in menstrual symptoms, and absenteeism
Acupuncture was superior to placebo and Chinese herbs in pain relief, and superior to medication and Chinese herbs in reducing menstrual symptoms. Acupressure was superior to placebo in pain relief and reducing menstrual symptoms
Low risk of bias in 50% of included RCTs
Abaraogu et al., 201543
Acupuncture or acupressure versus placebo control, wait list or pharmacological treatment in primary dysmenorrhea
Systematic review of 8 RCTs (> 3,000 subjects) and meta-analysis of 4 RCTs
Pain intensity (VAS, McGill scale), quality of life, and blood nitric oxide
Acupuncture and acupressure reduced pain, while acupuncture also improved quality of life
Moderate quality evidence
Chen et al., 201347
Acupuncture or acupressure at acupoint SP 6 versus minimal stimulation at SP 6 or stimulation of another point in primary dysmenorrhea
Meta-analysis of acupuncture (3) and acupressure (4) RCTs in primary dysmenorrhea
Pain intensity (VAS) Acupuncture is effective and acupressure may be effective at SP 6 for pain relief
Acupuncture trials had low-to-moderate risk of bias; acupressure trials had high risk of bias
Cho et al., 201044
Acupuncture versus sham acupuncture, pharma- cological treatment or Chinese herbs in primary dysmenorrhea
Systematic review of 27 RCTs in primary dysmenorrhea
Pain intensity (VAS, Menstrual Pain Reduction Score, and other pain scores)
Acupuncture was superior to pharmacological treatment or Chinese herbs in pain relief
Only 5 out of 27 trials had low risk of bias
Chung et al., 201246
Acupoint stimulation versus non-acupoint stimulation or medication in primary dysmenorrhea
Systematic review of 30 RCTs (> 3,000 subjects) and meta-analysis of 25 RCTs
Pain intensity, and plasma prostaglandin F2/ prostaglandin E2 ratio
Acupoint stimulation was superior in short-term pain relief to stimulation on non-acupoints. Non-invasive stimulation of acupoints was more effective than invasive stimulation
Some trials were of low quality
Xu et al., 201445
Various forms of acupoint stimulation (including acupuncture, moxibustion and other methods) versus a variety of controls in primary dysmenorrhea
Meta-analysis of 20 RCTs (2,134 subjects) of acupoint stimulation for primary dysmenorrhea
Pain relief Acupoint stimulation was more effective than controls for pain relief
Low-to-moderate quality evidence
RCT: randomized controlled trial; VAS: Visual Analog Scale; WOMAC: Western Ontario and McMaster Universities Osteoarthritis Index. There is currently debate within the scientific and academic communities on how to perform high-quality studies on acupuncture. It is widely recognized that standards applied to drug trials are inappropriate for acupuncture studies, as it is impossible to effectively blind patients to treatment with acupuncture as can be done with medications. Hence, this literature review, adhering to standards for drug studies, may undervalue some existing studies, and hence the strength of acupuncture for care may also be underestimated.
ACUPUNCTURE’S ROLE IN SOLVING THE OPIOID EPIDEMIC – WHITE PAPER 2017
Appendix 1. Effectiveness of Acupuncture continued
MJAOM | WINTER 2018 23
PERSPECTIVES
9. Acknowledgements
This paper was written and revised on the basis of original work
provided by the Joint Acupuncture Opioid Task Force (JAOTF). The
JAOTF was chaired by Bonnie M. Abel Bolash, MAc, LAc. The cur-
rent authors would like to thank the original contributors of that
paper: Matthew Bauer, LAc; Bonnie Bolash, LAc; Lindy Camardella,
LAc; Mel Hopper Koppelman, MSc; John McDonald, PhD, FAACMA;
Lindsay Meade, LAc; and David W. Miller, MD, LAc who come
from the Acupuncture Now Foundation (ANF) and the American
Society of Acupuncturists (ASA). We express thanks also to Jun Xu,
MD, LAc of the American Alliance for Professional Acupuncture
Safety (AAPAS) for fostering valuable collaboration on this project.
10. Competing interests
The authors declare that they have no competing interests.
Comments or corrections are welcomed and appreciated. Email
David W. Miller, MD, AAP, LAc: [email protected]
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52 MERIDIANS: The Journal of Acupuncture and Oriental Medicine | WINTER 2018
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