Report Recommends Treatment Be Integrated into National Health Service
By Michael Devitt
In the past decade, several national and international organizations have issued reports concerning the safety and efficacy of acupuncture.
The most well-known of these reports, the National Institutes of Health Consensus Development Statement, concluded in 1997 that "there is sufficient evidence · of acupuncture's value to expand its use into conventional medicine and to encourage further studies of its physiology and value."1
Now, the British Medical Association has offered its opinion on the subject. At the BMA's annual conference in London this June, the association published a report, Acupuncture: Efficacy, Safety and Practice,2 which acknowledges the scientific benefits of acupuncture and recommends that the treatment be incorporated into the National Health Service, Britian's national health care program.
"(Acupuncture) is clearly something that people are turning to in large numbers," said Dr. Vivienne Nathanson, head of health policy at the BMA. "And it is clearly something that GPs (general practitioners) are turning to in increasing numbers."
The current report is the result of a resolution passed at the BMA's annual representative meeting in 1998, at which a resolution was passed to "investigate the scientific basis and efficacy of acupuncture and the quality of training and standards of competence in its practitioners." The paper also represents the third time in the last 15 years that the BMA has published a major report on complementary and alternative care.
Acupuncture: Efficacy, Safety and Practice contains sections that study the efficacy and safety of acupuncture; the ways in which acupuncturists are taught; and the future development of the profession. The report also summarizes a BMA survey of general practitioners and their feelings toward complementary and alternative care, and issues recommendations as to how the delivery of acupuncture can be improved.
Safety and Efficacy of Acupuncture
The traditional "gold standard" of whether a treatment or procedure is effective is the randomized controlled trial (RCT). After examining several clinical trials of acupuncture for various medical conditions, the report concludes that acupuncture "is more effective than control interventions" for back pain, nausea and vomiting (most convincingly for post-operative symptoms in adults), migraine and dental pain.
Less conclusive results, meanwhile, have been found for conditions such as neck pain and osteoarthritis, recovery from stroke, tension headaches, temporomandibular joint dysfunction, smoking cessation and weight loss.
Regarding the safety of acupuncture, the report states that most adverse reactions generally fall into three main areas: physical injuries (such as cardiovascular trauma); infections from blood-borne viruses; and other adverse reactions (such as drowsiness or fainting after treatment).
Although some adverse reactions may be difficult to control, the report stresses that most physical injuries can be avoided with proper training in anatomy and physiology, particularly in terms of the depth and location of major organs. Transmission of infectious agents, meanwhile, could be greatly reduced by improving sterilization techniques or using only pre-sterile disposable needles instead of reusable needles.
Education and Training of Acupuncturists
Acupuncture can - and has been - taught and practiced in a variety of ways. In fact, the report concludes that "within agreed parameters," a certain amount of diversity in acupuncture training can be considered "healthy" in meeting the individual needs of students and the different approaches and practices among acupuncture instructors.
With such diversity, the report recommends that "a core curriculum for practitioners" be put in place that includes instruction in anatomy and physiology, research methods, acupuncture techniques, fundamentals of diagnosis, and ethics. These courses should be "of a credible duration" to provide students with the ability to practice acupuncture with an acceptable level of competency.
The report also recommends greater undergraduate training and accredited postgraduate training in acupuncture at medical schools.
"Because patients and doctors are turning to acupuncture in increasing numbers," said Dr. Nathanson, "doctors need more information about its safety, and medical students need better training while at university to give patients advice."
Future Developments in Acupuncture
Although there are no comprehensive acupuncture guidelines for general practitioners or patients, and there are no national regulatory and safety standard in place for acupuncturists in Great Britain, the profession continues to flourish. For acupuncture to continue growing, however, the BMA feels that more collaborative studies should be conducted to study the costs and benefits of treatment.
"There is a need for greater consensus on the part of the government, Department of Health, NHS Executive, the medical profession, and acupuncture organizations to provide guidelines and agree how acupuncture and other complementary and alternative medicine services can be integrated into the UK healthcare system," the report stated.
"We need to see more high-quality research into the effectiveness of acupuncture," added Dr. Nathanson. "We welcome complementary medicines into medical practice, but only based on robust research and robust training."
The report lists several recommendations for the integration, regulation and funding of acupuncture. Among the most noteworthy:
Consideration should be given to the creation of policies and guidelines that would make acupuncture more widely available to patients under the National Health Service.
A general list of all acupuncturists, medically and non-medically qualified, should be produced and maintained to facilitate the referral process for NHS doctors.
Further research should be conducted into the cost-effectiveness of acupuncture treatment, particularly for those conditions in which acupuncture has been identified as an effective form of care. Research should also be conducted into other conditions that may be usefully treated by acupuncture.
Acupuncture organizations should collaborate in creating a national system for the reporting of adverse events.
Relationships between acupuncturists, general practitioners and patients must be strengthened. An atmosphere of mutual respect should be promoted between GPs and their patients regarding the use of acupuncture. Doctors should ask about their patients' use of acupuncture and other alternative forms of care; acupuncturists, in turn, should recommend that their patients inform their GPs of their treatment.
Acupuncture should be included in any familiarization course on complementary and alternative medicine. Accredited postgraduate courses should be provided to inform doctors and other clinicians about acupuncture and its possible benefits.
All acupuncturists should be fully trained in infection control procedures, and immunization against hepatitis B should be considered for the protection of acupuncturists and their patients.
BMA Survey of Acupuncture in Primary Care
In addition to its review of acupuncture and recommendations, Acupuncture: Efficacy, Safety and Practice summarizes a survey of general practitioners in the United Kingdom to assess their use of (and attitudes toward) complementary and alternative medicine. A total of 365 GPs completed the survey, which was sent to every general practitioner in the country.
Of those who responded to the survey, more than half (58%) had arranged complementary or alternative therapies for their patients. Almost half of those surveyed reported arranging acupuncture treatment for their patients.
Acupuncture was also the most common form of alternative care used by general practitioners, and was used most commonly for pain relief and treating musculoskeletal disorders. It was most often performed in pain clinics or physiotherapy departments.
GPs' overall knowledge of acupuncture was found to be low. Only 16% said they had "considerable knowledge" of acupuncture or "knew a lot" about the subject; 82% said they had "very little" or only "basic" knowledge of complementary and alternative medicine. However, nearly half (46%) said they would like to receive further training in acupuncture in order to treat their own patients in the future.
In one of the most surprising statistics, a full 79% of practitioners reported that they would like to see acupuncture provided in the National Health Service. For this to happen, however, the survey concluded - as did the full report - that more rigorous clinical trials would need to be conducted.
Report Available Online
Acupuncture: Efficacy, Safety and Practice is available from the British Medical Association for £12.99 plus shipping and handling (note: at press time, £12.99 was roughly equal to $19.59 US). Practitioners interested in ordering a copy may visit the BMA's website (www.bma.org.uk), or they send an e-mail to the BMA's online bookstore (