This article is the fourth in a series designed to provide potential “acupuncture champions” with the information, perspectives, strategies, and tools necessary to successfully integrate acupuncture into their own clinics and medical centers.
Does it make sense for your hospital-based acupuncture resource to accept all the conditions that might be presented? Probably not. My guess is that you’ll want a solid evidence base backing your hospital’s acupuncture program. This article is designed to help uncover which indications to consider.
Which indications to include and exclude is as much an ethical consideration as it is a practice model choice made in the preparatory phases of starting a new acupuncture departments. We want to prevent our acupuncturists from burning out, and one angle which we can work on it from is in this area. If, as practitioners, we become inundated with inappropriate cases, it becomes more difficult to reach those patients that really needs our service and/or are likely to benefit the most from it.
The website Natural Standard is dedicated to assessing the scientific evidence regarding alternative and complementary therapies. The once self-proclaimed, “authority on integrative medicine,” has undergone a significant redesign of their site since I first discovered them in 2008. It is similar to the Cochrane Report in presenting meta-studies on the topic of acupuncture and making recommendations for the use of it based on the currently available evidence.
According to an early version of Natural Standard’s monograph on acupuncture, “Research on the effectiveness of acupuncture has special challenges. These include the diversity of approaches, the practice of individualizing treatment for each patient, differing skill levels between practitioners, and difficulty separating out the effects of acupuncture from placebo effects (i.e., how the patient’s beliefs and expectations affect his/her perception of symptoms).”
“Based on acupuncture’s long history of use as well as the limited research available, both the World Health Organization and the National Institutes of Health have identified many conditions for which it may be recommended. However, many common uses do not yet have formal scientific evidence to support them.”1
There’s currently an imperative in the U.S. to provide alternatives to opioid drugs for patients with pain syndromes.2 Considering acupuncture’s well-known ability to deal with pain, this seems like a no-brainer.
I would assert that when you look around at hospital acupuncture programs, you’ll see these indications being accepted most commonly:
• Chronic pain (greater than three months in duration)
• Nausea & vomiting due to chemotherapy
• Migraines and headaches
• Post-traumatic Stress Disorder / Trauma
Below is a breakdown of the evidence in acupuncture.
- Likely Effective: Osteoarthritis
- Possibly Effective: Back pain, cervical spondylosis, chemotherapy-induced nausea and vomiting, chronic daily headache, dental pain, fibromyalgia, insomnia, knee pain, labor pain, migraine, neck pain, post-operative nausea and vomiting, tendinopathy, tension headache
- Possibly Ineffective: Asthma, hearing loss, rheumatoid arthritis, urinary tract infections (UTIs)
- Insufficient Evidence: Alcoholism, allergic rhinitis (hayfever), angina pectoris, ankylosing spondylitis, anxiety, atrial fibrillation, autism, Bell’s palsy, breast cancer-related hot flashes, breast engorgement, breech presentation, cancer-related pain, carpal tunnel syndrome, cerebral palsy, chemotherapy toxicity, chronic obstructive pulmonary disease (COPD), cocaine dependence, depression, dry eye syndrome, dry mouth, dysmenorrhea, dyspepsia, endometriosis, endoscopy-related pain, enuresis, epilepsy, erectile dysfunction (ED), exercise performance, gastroparesis, hemiplegia, herpes zoster (shingles), HIV, hypertension, infertility, irritable bowel syndrome, kidney stones, labor induction, melasma, menopausal symptoms, myofascial pain, myofascitis, neurodermatitis, neurogenic bladder, opthlamoplegia, opiate withdrawal, pain, Parkinson’s disease, paroxysmal supra-ventricular tachycardia, peptic ulcers, peripheral neuropathy, post-hysterectomy pain, postoperative nausea and vomiting, postoperative pain, post-traumatic stress disorder (PTSD), pregnancy-induced nausea and vomiting, pregnancy-related pain, prostatitis, pruritus (itching), psoriasis, Raynaud’s syndrome, schizophrenia, shoulder pain, sinusitis, sleep apnea, smoking cessation, stroke, temporomandibular disorder, urinary incontinence, urticaria, tinnitus, Tourette’s syndrome, vascular dementia, vertigo, weight loss
I have successfully treated many of the conditions found under the heading, “Insufficient Evidence.” Others, not so much. Some conditions render dismal results in my practice, such as sleep apnea. Some I have obtained outstanding results with, as in the case of TMJ.
My point is that the status of a therapy’s scientific evidence is not always indicative of whether or not a patient will get a result for his or her condition. Even though idiopathic polyneuropathy may be considered to be a chronic pain problem, in my experience it is a difficult one to address using acupuncture.
We want to prevent the acupuncture department from becoming a “dumping ground” for cases that will tax the practitioner’s ability to achieve results and thereby stave off burnout. A hospital acupuncture practitioner will generally shoot for at least 70% of patients improving within a short course of acupuncture. Sending them nothing but the most recalcitrant and complicated cases will likely open you to the risk of turnover.
When assessing the current evidence base, please keep in mind that you may receive conflicting information based on who you are reading. Evidence-based medicine sites such as The Cochrane Collaboration have positive meta-study outcomes for acupuncture in certain conditions, such as migraine headaches.
Cochrane supports the use of acupuncture for migraines but the Natural Standard placed migraine headache in category “Possibly Effective.” The seemingly simple act of assessing the research turns out to be not so simple after all.
Here are some of my speculations as to why the “Insufficient Evidence” category above is so large:
• Acupuncture doesn’t fit that well within the RCT model of research
• There’s a number of poorly-designed studies or inconclusive studies on acupuncture
• Difficult conditions require experienced specialists to be able to get results with acupuncture
My previous employer, The Permanente Medical Group, Inc. was deciding on acceptable indications for acupuncture around 1979-80. They looked at the available evidence and ultimately decided on chronic pain instead of the more narrow diagnosis of osteoarthritis.
It was also quite clear to those decision makers that nausea and vomiting due to chemotherapy ought to be included since there was a high level of evidence for it.
There’s a lot of acupuncture research happening right now, so hopefully, we can confidently add indications later as they become a part of the evidence base. I expect the total number of viable indications for hospital-based acupuncture practices to increase over time so it’s prudent to keep your finger on the pulse of the current state of research. I know that the leaders at TPMG with whom I worked made at least one formal literature review regarding acupuncture per year.
I will encourage you, the “acupuncture champion” in charge of on-boarding licensed acupuncturists, to also think outside the evidence-based paradigm. Put on your ‘strategic hat’ for a moment, and think about the broader needs of your patient population.
Think about those patients who find themselves in difficult predicaments, such as not being able to take medication or those who are not candidates for surgery. What can you offer them? Many underserved or poorly served patient populations (such as chronic fatigue syndrome patients) need help with their medical conditions too.
I have the strong sense that it is possible to cut down on or prevent entirely emergency department visits by certain at-risk patient populations by getting them into an acupuncture program. In particular, the chronic pain patients stand to benefit greatly from the option of acupuncture treatment. It will always be less expensive to the medical center to see a patient in an acupuncture clinic rather than the ER.
Of course, it’s also plausible to run an acupuncture pilot of your own. These do not require a lot of resources and can be carried out in short order at your facility. I personally ran a pilot at Kaiser Permanente in 2015-16, so feel free to contact me if you need help designing a pilot study for your facility.
In conclusion, I’ll encourage you to choose wisely when setting up acceptable indications in your acupuncture department. Good decisions here can help support the success of your acupuncture program, mitigate risks, and make the greatest medical impacts in your patient population.