Understanding the Challenges of U.S. Acupuncture Practice (Pt. 1)

This multi-part article provides a review of the literature related to factors associated with the challenges of current U.S. acupuncture practice. Considering the complexity of the acupuncture practice, we chose Neal and Neal’s networked model as the theoretical framework to explore the literature associated with the challenges of practice, because this model focuses on the patterns of participants’ social interactions within and across the different systems.¹

In the early 19^th century, acupuncture was introduced in the United States, where the practice was used by both Western medical doctors and Chinese medicine doctors.² Although some Western medical doctors used acupuncture at that time, there were still some doctors in the U.S. who distrusted and questioned the effectiveness of acupuncture throughout the entire 19^th century until the present.  However, Cassedy argues that acupuncture did not die out in the United States because, occasionally, Western physicians were interested in keeping this practice alive.²

Although there was skepticism, since the 1970s acupuncture has gained the U.S. public’s interest, especially after James Reston, former editor of The New York Times, published a story about the pain relief he felt from acupuncture treatment after his emergency appendectomy.³ Subsequently, acupuncture has been increasingly utilized by the U.S. public.

Current Status of Acupuncture in the U.S.

The U.S. population increased use of acupuncture by 63% between 2002 and 2012.^4-5 According to the 2012 National Health Interview Survey (NHIS), 6.7% (12.7 million) Americans reported using acupuncture in their lifetime.⁶

In addition to the U.S. public’s acceptance, today, acupuncture as a practice and a component of the health care system has experienced awareness across other health professions.⁷ Besides some physicians and nurse practitioners using acupuncture, other common health care professions performing acupuncture include chiropractic and physical therapy.

The chiropractic profession allows practitioners who have limited hours of acupuncture training to add acupuncture in their practice in 30 states and the District of Columbia.⁸ Physical therapists in more than 30 states perform dry needling, which is considered a form of acupuncture by acupuncturists.⁹

With the increased demand for acupuncture, the number of licensees for acupuncture professionals has increased accordingly.¹⁰ A study by Fan, et al., indicates that the number of licensed acupuncturists in the United States in early 2018 was 37,886, an increase of 9.88%, 35.48%, and 67.11%, respectively, compared to 2015 (n=34,481), 2009 (n = 27,965), and 2004 (n = 22,671).¹¹  

Moreover, per McKenzie, et al., all but four states have passed acupuncture regulatory legislation. The most recent states to update their legislation in 2018 were Alabama, South Dakota and Oklahoma.¹² All these data demonstrate that acupuncture is growing as a health care profession in the U.S.

There are well-established statistics data for chiropractic care and massage therapy in the Bureau of Labor and Statistics (BLS). However, the BLS only started to list acupuncture as a profession in 2018; therefore, no previous occupational data, such as job functions, training and education, practice settings, and income of acupuncturists, are available.¹³

Furthermore, the few studies that are available provide an inaccurate picture of acupuncture as a work force in the United States because the acupuncture profession did not have a unique occupational code listed by the BLS until 2018.¹⁴ Without precise and frequent occupational data for the acupuncture work force, it is difficult to track and analyze the development of the profession.^14-15

The Relationship Between Acupuncture & Mainstream Medicine

As briefly mentioned in the previous section, the relationship between acupuncture and mainstream medicine has had a long and contentious history. When focusing on mainstream inclusion of acupuncture, the most common term understood by the mainstream health care system is integrated medicine, which means the selective incorporation of acupuncture into comprehensive care. Physicians prefer this type of integration, as it ensures they remain in control.⁷

Although more U.S. medical schools have established programs of study in integrative medicine, they do not always know the best way to practice integrative medicine.¹⁶ There is also no established standard to manage the integrative medicine program regarding the organizational settings, multidisciplinary team training, research initiatives, and financial issues.¹⁶

Additionally, acupuncture training in U.S. acupuncture schools does not ensure graduates have sufficient biomedical knowledge.¹⁷ As a result, the acupuncture profession fails to integrate into mainstream medicine fully.¹⁸

Similarly, Austin, et al., argue that acupuncture’s utilization has not been woven into mainstream medical treatment in the United States.⁶ And as Kielczynska, et al., highlight, “The hospital setting [has] placed significant limitations on how the acupuncturist could utilize their holistic approach to care.”¹⁹ There exist opportunities to integrate acupuncture into mainstream medicine, but also challenges to adoption due to incompatibilities between the two medical systems.¹⁹

The Challenges of Acupuncture Practice

From time to time, athletes, movie stars and other celebrities (such as Prince Harry and Meghan Markle) have publicly reported receiving regular acupuncture treatments, which may demonstrate that acupuncture is becoming more and more popular. Over the past decade, acupuncture has gained particular attention from the public and has grown quickly in the U.S.⁴ Simultaneously, the number of acupuncturists and number of accredited programs in acupuncture and Asian medicine have increased.¹¹

In 2017, acupuncture, as one of the nonpharmacologic therapies for low back pain, was recommended by the American College of Physicians for the first time.²⁰ The FDA has proposed that doctors should be aware of the nonpharmacologic treatment options, including complementary therapies for pain management. And in 2018, the Department of Veterans Affairs’ handbook established a qualification standard for acupuncturists’ employment within the VA Health Administration.^13,21-22

Despite this increased attention and use, according to Austin, et al., mainstream medical professionals do not often refer patients to acupuncture treatment.⁷ In addition, Kielczynska, et al., suggest the “acupuncture profession is poorly integrated into the American health care system.”¹⁹

Therefore, the primary challenge of current acupuncture practice is that mainstream U.S. medicine practitioners do not frequently include acupuncture as a possible option for their patients, which indicates acupuncture is not included in U.S. mainstream medicine.

References

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2. Cassedy JH. Early uses of acupuncture in the United States, with an addendum (1826) by Franklin Bache, MD. Bulletin NY Acad Med, 1974;50:892.
3. Reston J. “Now, Let Me Tell You About My Appendectomy in Peking.” The New York Times, 1971.
4. Burke A, Upchurch D, Claire D, Chyu L. Acupuncture use in the United States: findings from the National Health Interview Survey. J Alt Compl Med, 2006;12:639-648.
5. Clarke TC, Black LI, Stussman BJ, et al. Trends in the use of complementary health approaches among adults: United States, 2002–2012. Nat Health Stat Rep, 2015;79:1.
6. Austin S, Ramamonjiarivelo Z, Qu H, Ellis-Griffith G. Acupuncture use in the United States: who, where, why, and at what price? Health Market Quart, 2015;32:113-128.
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8. Brown S. “Can DCs Get Certified in Acupuncture?” Chiro Economics, June 12, 2018. 
9. Reno J. “Acupuncturists and Physical Therapists Declare War Over ‘Dry Needling’.” Healthline.com, Sept. 7, 2016.
10. Fan AY, Faggert S. Distribution of licensed acupuncturists and educational institutions in the United States in early 2015. J Integ Med, 2018;16(1):1-5.
11. Fan AY, Stumpf SH, Alemi SF, Matecki A. Distribution of licensed acupuncturists and educational institutions in the United States at the start of 2018. Compl Ther Med, 2018;41:295-301.
12. McKenzie M, Sale D, Ward-Cook K, et al. Acupuncture and Oriental Medicine. Clinicians’ and Educators’ Desk Reference on the Integrative Health and Medicine Professions, 2017.
13. “Acupuncture Earns Unique Occupational Code From U.S. Bureau of Labor Statistics. National Certification Commission for Acupuncture and Oriental Medicine, 2018.
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16. Eisenberg DM, Kaptchuk T, Post DE, et al. Establishing an integrative medicine program within an academic health center: essential considerations. Acad Med, 2016;91:1223.
17. Kendall DE. Energy-meridian misconceptions of Chinese medicine. Schweizerische Zeitschrift Fur Ganzheits Medizin (Swiss J Integ Med), 2008;20:112-117.
18. Stumpf SH, Hardy ML, McCuaig S, et al. Acupuncture practice acts: a profession’s growing pains. J Sci Healing, 2015;11:217-221.
19. Kielczynska BB, Kligler B, Specchio E. Integrating acupuncture in an inpatient setting. Qualitative Health Res, 2014;24:1242-1252.
20. Chou R, Deyo R, Friedly J, et al. Nonpharmacologic therapies for low back pain: A systematic review for an American college of physicians clinical practice guideline. Ann Intern Med, 2017;166(7):493-505.
21. FDA Education Blueprint for Health Care Providers Involved in the Treatment and Monitoring of Patients With Pain. U.S. Food & Drug Administration, 2018.
22. VA handbook 5005/100. Department of Veterans Affairs, Feb. 7, 2018.