Pauline Anderson

October 30, 2017

SAN DIEGO — The last two decades have seen "unprecedented advances" in the use of acupuncture to treat pain conditions, with a "rapid rise" in the number and quality of related published studies, according to a physician who is an experienced acupuncture practitioner.

"Right now, we have a pretty solid foundation for the efficacy of acupuncture" for headache, osteoarthritis (OA), and musculoskeletal conditions, said Farshad M. Ahadian, MD, clinical professor of anesthesiology, University of California, San Diego.

"I think it's fair to say that acupuncture is here to stay. It's going to be a permanent addition to our tool box."

Dr Ahadian presented the data here at the Academy of Integrative Pain Management (AIPM) 28th Annual Meeting.

Opioid Epidemic Rages On

To reach their "full potential," clinicians need to "fully integrate" conventional medicine with alternative therapies, which includes acupuncture, Dr Ahadian told meeting delegates.

This may be increasingly important because of two "really important critical challenges":  the opioid epidemic and the aging population.

"The opioid epidemic has been raging for two decades, and there seems to be no end in sight. And I don't think we have woken up to the implications that an aging population has for the prevalence of chronic pain."

During his presentation, Dr Ahadian reviewed some of the extensive literature on acupuncture for chronic pain. Between 1997 and 2010, over 600 related clinical trials were published.

One recent review,  which Dr Ahadian described as "one of the most academically rigorous" analyses, was independently funded by the National Institute for Health Research in the United Kingdom.

After screening almost 1000 publications, researchers selected 29 of the highest-quality randomized controlled trials. The studies compared true acupuncture with sham acupuncture (needling that did not penetrate the skin or needling at the wrong points) or no acupuncture (standard medical care) in almost 18,000 patients.

The authors carried out an individual patient data meta-analysis, which Dr Ahadian said was "unique" for this kind of research.

"Instead of 29 data points, they actually had almost 18,000 data points, so it was a much more powerful means of gathering data."

The analysis showed that acupuncture was statistically superior to both sham acupuncture and nonacupuncture across several pain conditions, including neck and lower back pain, OA of the knee, headache, and migraine (all P for overall effect = .001).

The effect size for sham acupuncture was "a little bit smaller" than for nonacupuncture, said Dr Ahadian.

"That underscores the powerful effect of placebo that is associated with any type of physical modality, including acupuncture," he said. He added that this presents "challenges for acupuncture research."

The analysis also confirmed that acupuncture had "clinically meaningful effects, which is important," said Dr Ahadian.

Clinically Meaningful Results

Other research has shown that acupuncture increases functional connectivity.

"Chronic pain can lead to abnormal patterns or disruption of functional connectivity in various brain centers," explained Dr Ahadian. He added that acupuncture "can help modulate and help normalize" functional connectivity.

He pointed to another study  that included patients with moderate to severe knee OA who were acupuncture naive and had not had any interventions in the prior 6 months. Patients were randomly assigned to receive true acupuncture or sham acupuncture.

Each participant received six treatments over a 1-month period. They also underwent functional MRI.

Using the validated Knee injury and OA Outcome Score (KOOS), researchers found that the interaction between groups (real vs sham) and time (baseline vs endpoint) was significant for the KOOS subscale scores for pain (P = .025), function in sport (P = .049), and quality of life (P = .039).

The analysis demonstrated statistically significant improvement in functional connectivity in the right frontal parietal network and the executive control network, "which are the brain centers that are felt to play a significant role" in processing pain, said Dr Ahadian.

At the same time, there was decreased connectivity in the sensory motor network, he said. "These are patterns that you would expect with improved pain control."

The results were clinically meaningful, noted Dr Ahadian. The study found that after treatment, the increase in functional connectivity was positively correlated with changes in KOOS pain scores.

In traditional Chinese medicine, pain and illness are believed to be caused by an obstruction to the normal flow of qi (vital energy). It might be that functional connectivity is correlated to qi, said Dr Ahadian.

"Could it be that when we talk about removing these obstructions, what we're talking about is actually improving functional connectivity?"

Dr Ahadian stressed that finding effective alternative therapies to treat chronic pain is increasingly important in an era characterized by skyrocketing opioid-related deaths. In 2015, there were 33,091 such deaths in the United States, he said.

Another factor that should stimulate the search for effective pain therapies is the growing elderly population. The percentage of those aged 65 years and older was 13% in 2012 but is expected to rise to 20% by 2050. The incidence of chronic pain increases with age.

Training

In addressing a query from an audience member about training, Dr Ahadian referred him to the American Academy of Medical Acupuncture (AAMA), the professional society of physicians who have incorporated acupuncture into their medical practice. 

According to the AAMA website, membership requirements have been established in accordance with training guidelines created by the World Health Organization–recognized World Federation of Acupuncture-Moxibustion Societies. 

Other delegates were curious about the optimal number of acupuncture treatments and response times.

While some experts advise patients they need to try up to 20 treatments to know whether the treatment is working, "in my experience, if you don't have some positive response within maybe 4 or 5 treatments, you may need to think twice," said Dr Ahadian.

He noted that "not everybody is a great acupuncture responder."

Certain factors may reduce a patient's "acupuncture responsiveness. Acupuncture relies on an intact nervous system to cause its effect, so if patients have significant peripheral neuropathy, or other neuropathies, they may not be as responsive," he said.

Once patients do respond, Dr Ahadian said he attempts to increase the interval between treatments while sustaining the results.

"Our goal in medicine is not to marry the patient to our office and have patients come in all the time," he said.

"If I can't get persistent efficacy, or reasonable efficacy, lasting a month, then I may advise against it or I may need to figure out how to change my therapy."

In a keynote address elsewhere at the AIPM meeting, retired US Army Colonel Gregory D. Gadson, who lost both legs due to a roadside bomb blast while serving in Baghdad in 2007, and now suffers chronic pain, said he still receives occasional "battlefield acupuncture."

When asked by Medscape Medical News about "battlefield acupuncture," Dr Ahadian explained that it involves a brief session using small needles in the skin of the ear to block pain. The treatment can be administered in as little as 5 minutes and is being used to treat wounded US service members.

Dr Ahadian reports that he receives principal investigator research support from Boston Scientific and Mainstay Medical.

Academy of Integrative Pain Management (AIPM) 28th Annual Meeting. Presented October 22, 2017

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