In response to the epidemic rates of opioid and heroin addiction, the Centers for Disease Control and Prevention (CDC) set new guidelines for physicians regarding treatment for pain. In an attempt to reduce the amount of opioids being prescribed, the CDC has listed guidelines for pain management that identify specific alternative approaches. These treatments range from various types of nonopioid medications, behavioral therapy, exercise therapy and epidural injections. Noticeably missing from these new guidelines for the treatment of pain is acupuncture.
The CDC explains what they describe are not recommendations, but rather "guidelines" for pain management geared for primary care physicians. For chronic pain excluding areas that involve active cancer treatment, palliative care, and end-of-life care, the guidelines describe substituting other drugs such as NSAIDs, antidepressants, and anticonvulsant types of drugs used for nerve pain.
An article in March of this year on Medscape Medical News titled, "CDC Issues Opioid Guidelines for ‘Doctor-Driven' Epidemic," received more than 300 comments from doctors, nurses, and healthcare administrators.1 Comments summed up majority voiced concerns about moving in a direction that in essence may create unintended consequences. Most did not feel confident about the new guidelines as set forth by the CDC. Concerns ranged from depriving patients of adequate amounts of opioid pain medication to control pain, to a greater reliance on the nonopioid drugs that have their own set of serious side effects. Some expressed concerns regarding the suicide risk for patients whose pain is not adequately addressed or managed. Still others spoke out about how the pharmaceutical industries role greatly contributed to the problems we see today taking place with the high rate of addiction to opioids.
When the CDC released their new opioid guidelines, it lit up the Internet. The report went viral to medical organizations and healthcare groups. Those with interests in this area were fervently discussing the new CDC guidelines. Many online reports had hundreds of comments and responses such as with Medscape. Discussion included the alternative treatments as described by the CDC in the categories of the nonopioid pharmacological approaches, cognitive behavioral therapy and exercise therapy or PT. Acupuncture was not included in most of these discussions for the sole reason that it was not included in the CDC guidelines. Sadly, this served to push acupuncture even further from the thoughts of referring physicians.
We welcome the CDC's list of specific types of alternative modalities for the treatment of pain. In question are a list of approaches that exclude any mention of acupuncture especially given how these guidelines were written in response to the opioid epidemic we are left as a nation to address. Acupuncture in the United States has had an active and important role in both pain management and substance addiction for nearly half a century now. It is concerning that there is no mention of acupuncture by the CDC, especially given the wide body of research evidence supporting the effectiveness and safety of acupuncture in the treatment of pain. In the United States, peer reviewed studies have allowed acupuncture to be included as an evidenced-based medicine.
As with so many types of treatment, conflicting studies have become increasingly common, confusing even the most adept experts responsible for patient care. In order to address this issue with acupuncture, the National Institute of Health funded a large-scale study completed in 2012.2 A rigorously detailed meta-analysis of data was conducted with a total of 17,922 patients involving the use of acupuncture for pain. Conducted over a six-year period, four different chronic pain conditions were analyzed consisting of back and neck pain, osteoarthritis, chronic headache and shoulder pain. There were multiple types of control groups to which acupuncture was compared. The study demonstrated significant differences between true and sham acupuncture indicating acupuncture is more than a placebo. The study concluded that, "acupuncture is effective for the treatment of chronic pain and is therefore a reasonable referral option."
The CDC cited research criteria upon which treatment modalities must qualify. Though acupuncture appears to fall well within the CDC research parameters for inclusion, it was never identified as part of their guidelines for treatment options. Modalities that met with their research criteria as specifically listed by the CDC include the following: Cognitive behavioral therapy "CBT," "exercise therapy" as a "prominent modality in physical therapy" and "multimodal and multidisciplinary therapies (e.g., therapies that combine exercise and related therapies with psychologically based approaches)." Nonopioid pharmacologic approaches used for pain include "analgesics such as acetaminophen, NSAIDs and COX-2 inhibitors; selected anticonvulsants; and selected antidepressants (particularly tricyclics and serotonin and norepinephrine reuptake inhibitors [SNRIs])." The CDC acknowledges side effects for acetaminophen, NSAIDs and COX-2 inhibitors and with this offers up alternatives for neuropathic pain that include anticonvulsants (gabapentin or pregabalin), tricyclic antidepressants and SNRIs. Interventional approaches such as epidural injection for lumbar radiculopathy are also cited as effective with caution.3
One has to wonder why the CDC would omit mention of acupuncture as a viable form of treatment for pain management, but specifies other treatment options for referral. A treatment modality identified by the CDC that met their research criteria for pain management is cognitive behavioral therapy. The CDC recommends CBT for the treatment of back pain, as well as pain in general. Thus, they are including for referral all mental health therapists who incorporate or specialize in this type of behavioral approach. Mental health therapists are the only new addition to other types of practitioners who would receive referrals from primary care clinicians specifically for pain management. The other treatment option for referral that met with the CDC guidelines is "exercise therapy" as "a prominent modality in physical therapy" for the treatment of pain. Thus the CDC is referencing physical therapists for referral as the major group specializing in this area. Referral to a PT is often already the go-to response by physicians to address specific types of pain.
The CDC relied upon expert opinions from what they identify to be the "Core Expert Group" and invited reviews of the guidelines from a "Stakeholder Review Group." It is not clear whether the CDC through their experts considered acupuncture as not meeting the research criteria, or whether they assume acupuncture (unidentified as such) would be considered an option as part of their generic category of approaches designated as "multimodal and multidisciplinary therapies." Even if we assume the latter, the CDC's own definition of such therapies as based on exercise or psychological approaches is likely to preclude a physician from even considering referral for acupuncture treatment.
Effective pain management in lieu of opioids, especially for chronic syndromes, requires all hands on deck. If the CDC is serious about physicians helping to provide pain patients with the best possible options that do not include opioid prescriptions, acupuncture needs to be identified in these guidelines as a proven treatment. With the high rate of opioid and heroin addiction, acupuncture is an important cost effective option that can treat a vast array of acute and chronic pain conditions, as well as assist with treatment for substance addiction.
Regardless of what the CDC suggests in terms of treatment, patients in pain will continue to seek out acupuncturists. Concern is for the portions of our population who would not know to seek out acupuncture without a referral. According to the new CDC guidelines to reduce dependency upon opioids, it doesn't look like referrals to acupuncturists from physicians will be anywhere on their list soon. If the CDC is serious about effective approaches for reducing the amount of opioids prescribed, acupuncture needs to become an integral part of these referral equations used to help guide physicians.
References:
Chronic pain afflicts over 20% of the adult population. Sadly, most MDs have essentially no education in treating pain, beyond offering a few toxic medications. Then they tend to steer people with pain away from those health practitioners who are trained. This puts the acupuncture community on the front lines for addressing this epidemic.
When the body is going through a stressful event, the sympathetic system is activated. This activation will help the body with a life-threatening situation. If this state is activated for prolonged periods of time, it starts to consume energy. These traumatic events that generate stressors in the autonomic nervous system (ANS) will eventually become internalized.
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One of the things that makes acupuncture so difficult to measure is that the medicine actually does contain some esoteric aspects. There have been numerous studies that demonstrate the neurochemical reasoning behind why acupuncture points stimulate the autonomic nervous system to enact change However, not all the benefits of TCM can easily be measured by randomized, controlled trials. But does that make them fundamentally and definitively untrue?
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