According to Professor Hugh MacPherson of the University of York in the UK, “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.”
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. The guidelines govern which treatments GPs in the NHS can offer to their patients who suffer with back pain.
Acupuncture has been removed as a recommended treatment. This decision reverses the one made by the 2009 committee, who included acupuncture on the basis of robust evidence.
The reversal by this committee stands in contrast to recommendations by research and policy institutions in other countries - the United States, Canada, Germany and Australia. These countries 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.
Practitioners and academics from throughout the world and united through the Acupuncture Now Foundation have come together to provide the full story behind the decision.
While the evidence of acupuncture’s safety and effectiveness is now stronger than in 2009, the NICE 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, as they have limited clinical relevance for GPs and their patients.
NICE found that real acupuncture did outperform 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. Their superiority over usual care was less than that for acupuncture yet still it was decided to exclude acupuncture. By requiring acupuncture to outperform sham treatment, whilst not requiring the same of exercise or manual therapies for example, represents a bias in recognised guideline development practice, where great lengths are normally taken to compare treatments using the same measuring stick. NICE has not adequately justified why acupuncture alone was singled out in this way.
The NHS spends over £300 million pounds treating injuries caused by the use of non-steroidal anti-inflammatory drugs (NSAIDs). Conditions such as GI bleeds and heart failure result in two thousand preventable deaths every year in the UK. The new guidelines do caution that doctors should recommend the lowest dose of NSAIDs for the shortest amount of time possible.
Recommending access to acupuncture as an effective drug-free alternative to treat low back pain could easily lead to a reduction in the intake of harmful medications.
The updated recommendations will mean reduced choice for patients and their health care providers. 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. Providers will be left with less effective options that potentially may carry greater risks. This decision to not recommend acupuncture takes away patient choice and may well result in more serious adverse events for patients as well as greater long term cost to the NHS.
In New Zealand, patient treatments and GP referrals are not constrained by NICE guidelines, however, New Zealand GPs may well be influenced by these guidelines to not recommend acupuncture, a safe and drug-free treatment that is proven to be effective for the treatment of low back pain. Acupuncture NZ members have been recognised by ACC as Treatment Providers since 1990 and GPs throughout the country frequently refer their patients for acupuncture treatment.
For more information contact:
Paddy McBride 021 104 3592 firstname.lastname@example.org
Kate Roberts 027 672 7244 email@example.com or
Dan Jakes 021 408 036 firstname.lastname@example.org