Learning Objectives: After participating in this continuing professional development activity, the provider should be better able to:
1. Explain the incorporation of acupuncture as an adjuvant for relief of cancer pain.
2. Summarize how acupuncture can be incorporated into postoperative pain management strategies.
3. Identify the ability to reduce opioid use by substitution of acupuncture.
Acupuncture, recognized as a form of alternative medicine and a component of traditional Chinese medicine (TCM), uses thin needles inserted into the body. In the United States, there are a number of US-trained physicians and even veterinarians who also practice acupuncture. And there are many more such Western-medicine practitioners who recognize that TCM has benefits. They are aware that their patients might undergo TCM and that a number of these patients report benefits that might complement their medical and surgical care.
However, acupuncture and TCM are not widely understood or accepted by the US medical establishment, or even by most of the US population. There are those who have referred to acupuncture as a pseudoscience.1,2 In other words, the theories and practices of TCM are not based on rigorous scientific knowledge. Some have even called it quackery.3
Nevertheless, acupuncture treatment has been around for thousands of years and in many countries throughout the world. Its use can be traced back for at least 2500 years to the rule of Emperor Huang Ti (2695-2597 BC).4 Huang Ti is said to be the author of the Nei Ching Su Wen, sometimes spelled Huangdi Neijing. The more recent (1949) English translation by Ilza Veith has the title translated to "The Yellow Emperor's Classic of Internal Medicine," published in 1949 by the University of California Press (Figure 1).
The first part, the Nei Ching, consists of long discussions between the emperor and his chief physician, Ch'I Po, on the indications for the use of acupuncture and the conditions that respond best to it. Even at that time, use of acupuncture for the alleviation of pain was discussed.
A more modern publication, "The Yellow Emperor's Book of Acupuncture," translated from Chinese by Henry Lu and published by the Academy of Oriental Heritage in 1973, describes in depth more of the history, meridians, and uses of acupuncture, but depends mostly on the writings from the Yellow Emperor (Figure 2).
Acupuncture is purported to be based on the assumption that there are patterns of energy flow through the body that are vital for health, although these theories have been disputed. The meridians and points used in acupuncture can be seen in models (Figures 3 and 4). The energy flow is called qi, sometimes spelled chi, and, in either spelling, pronounced "chee."1 In fact, the use of qi as an explanatory framework has been decreasing in China, even as it becomes more prominent during discussions of acupuncture in the United States.5
TCM aims to find the cause of pain due supposedly to blockages and imbalances of the flow of qi or from insufficient blood supply. By using fine needles, traditionally gold or silver (Figure 5) but now more likely to be made of steel, at specific acupuncture points, the recovery of health can be achieved, thus improving blood supply and decreasing the sensation of pain.
Acupuncture has had a varied history in resurgence and decline. Chairman Mao Tse-Tung spoke of the necessity of cooperation between doctors of traditional and Western medicine, and so he supported training teachers and writing textbooks. The Academy of Traditional Chinese Medicine and the Research Institute of Acupuncture and Moxibustion were simultaneously established in 1955. Although online diploma classes advertise to provide experience in acupuncture, as of now, each state in the United States has its own regulations and requirements when it comes to the practice of acupuncture. Not all US physicians holding an MD degree and license can practice the art without specialty training. Rather, as the needs and usages of acupuncture increase, it is important that guidelines and practice parameters with specified training programs be widespread. The global acupuncture market was worth $24.55 billion in 2017. The market was led by Europe, with a 32.7% share, followed by Asia-Pacific with a 29.4% share and the Americas with a 25.3% share. It is estimated that this year the industry will reach a market size of $55 billion.6
Several studies suggest that the mechanism of effect of acupuncture can be explained in biomedical terms.7 A number of transmitters and modulators including [beta]-endorphin, serotonin, substance P, interleukins, and calcitonin gene-related peptide are released. For that reason, acupuncture can be used in a wide variety of clinical conditions. Older studies showed that acupuncture may have beneficial effect in the perioperative period by relieving anxiety, decreasing postoperative analgesic requirements, and decreasing the incidence of postoperative nausea and vomiting. By extension, these valuable actions could be applied to many medical scenarios.7
In this year alone, 1571 articles have been published in PubMed regarding new applications for acupuncture. A few are reviewed in this article.
Use in Pain Management and Opioid Abuse
Therapists often attribute pain relief to the release of endorphins that occur when needles penetrate the skin. Some studies suggest acupuncture causes a series of events within the central nervous system, and that it is possible to inhibit or reverse acupuncture's analgesic effects with the opioid antagonist naloxone.8,9 Mechanical deformation of the skin by needles may result in the release of adenosine.10 The antinociceptive effect of acupuncture may be mediated by the adenosine A1 receptor. Other studies have refuted this idea. A review in Nature Reviews Cancer analyzed mouse studies that suggested acupuncture relieves pain via the release of adenosine, triggering nearby A1 receptors. The review demonstrated that in those studies, because acupuncture caused more tissue damage and inflammation relative to the size of the animal in mice than in humans, such studies unnecessarily confused a finding that local inflammation can result in the local release of adenosine with analgesic effect.11
A 2018 National Survey on Drug Use and Health estimated that there were 9.9 million people misusing prescription opioids in 2018, including 1.9 million new misusers. Most likely those numbers have increased since the publication of that report. Could the addition of acupuncture to other modalities decrease the need for opioids?
Acupuncture has been increasingly used in patients with chronic pain. A recent study of 1616 articles showed that the number of annual publications on acupuncture for chronic pain has increased over time, with the main types of literature being original articles (1091 articles, 67.5%), and review articles (351 articles, 21.7 %).12
Most publications were from China (598 articles, 37 %), with Beijing University of Traditional Chinese Medicine (93 articles, 5.8%). Evidence-Based Complementary and Alternative Medicine ranked first (169 articles, 10.45%) as the most prolific affiliate and prescribed journal. Liang FR was the most productive author (43 articles). The article published by Andrew J. Vickers in 2012 had the highest number of citations (625 citations). Recently, "acupuncture" and "pain" appeared most frequently. The hot topics in acupuncture for chronic pain, based on keywords clustering analysis, were experimental design, hot diseases, interventions, and mechanism studies. The main research frontiers were functional connectivity, depression, and risk.
Opioid abuse has entered the national dialogue as an epidemic, and the crisis has worsened with the COVID-19 pandemic.13 Opioid abuse often stems from overprescribing of opioid during or after surgery or from treatment of chronic conditions. Many studies have looked at alternate means to reduce opioid use, by implementing multianalgesic techniques.
Given that there are almost no adverse consequences of acupuncture in trained hands, recent studies suggest that adding the technique to a pain management strategy may help reduce the number of opioids consumed and reduce nausea, vomiting, and pain.14 The authors found that incorporating intraoperative electroacupuncture, also called auricular acupuncture, into an existing multimodal analgesia regimen is a feasible way to maintain a low-dose opioid regimen for patients undergoing primary unilateral total knee arthroplasty. Of patients who completed the study, 65% maintained a low-dose opioid regimen, 7% remained opioid-free for 30 days, and all patients stopped using opioids by 30 days after surgery.
Depression and Anxiety
Acupuncture combined with antidepressant pharmacologic treatment may not only improve primary and secondary depressive symptoms but also reduce the side effects of the medical treatment. Such side effects in combination with the slow onset of beneficial effects of antidepressants are the main cause for high dropout rates with drug treatment. Studies in animal models of depression and in patients have shown that acupuncture could increase hippocampal and network neuroplasticity and decrease brain inflammation, potentially to alleviating depressive disorders.15
Another study reviewed 31 meta-analysis (MA) studies and 59 randomized clinical trials and demonstrated conflicting results.16 Acupuncture may confer small benefit and was better than no treatment in reducing the severity of depression. Six MAs concluded that acupuncture reduced the incidence of adverse events compared with antidepressants. Another study in postpartum depression yielded similar findings, reporting limited effectiveness but that the effects were better than nothing.17
A Cochrane database report seemed to concur with the general findings.18 The reduction in severity of depression was less when acupuncture was compared with control acupuncture than when acupuncture was compared with no treatment control, although in both cases, results were rated as providing low-quality evidence.
The effect of acupuncture compared with psychological therapy is unclear. The risk of adverse events with acupuncture is also unclear, as most trials did not report adverse events adequately. Few studies included follow-up periods or assessed important outcomes such as quality of life.
Regarding management of methamphetamine addicts during abstinence, electroacupuncture was shown to help improve psychiatric symptoms and anxiety and depression, and promote rehabilitation.19
However, in conclusion, evidence from animal and human research supports some beneficial effect of acupuncture in depression, for the most part. Clinical trials are small, and it is unclear whether their findings can be generalized, so most authors suggest that more studies are needed.
The Cardiovascular System
A total of 7 trials involving 893 subjects examined the effect of acupuncture on management of chronic stable angina pectoris (CSAP). MA results showed that acupuncture combined with standard care was more effective in relieving anxiety and depression, reducing angina attack frequency, and reducing angina pain intensity than sham acupuncture with standard care and standard care alone. Although the effect was ranked as low to moderate with a greater decrease in depression,20 the authors concluded that acupuncture may be used as an adjunctive therapy to treat CSAP-associated anxiety and depression. Again, more high-quality randomized controlled trials (RCTs) are required to confirm the findings.
Several studies have demonstrated that acupuncture can influence autonomic nervous system functions. Heart rate variability is a widely used marker of autonomic activity. Researchers identified 1698 relevant articles from a literature review that included 9 randomized clinical trials.21 The statistical analysis of the available data showed that the changes between pre- and posttreatment HF (high frequency) and LF/HF (high frequency/low frequency) values in the real acupuncture group were significant. Meanwhile, there were no significant changes in these parameters in sham groups, indicating that real (vs sham) acupuncture has superior effect over placebo acupuncture in increasing parasympathetic tone, and in this way may improve physical well-being. Due to the quality of primary studies and degree of heterogeneity, the results should be interpreted cautiously.
Acupuncture has also been used for years in the clinical treatment of essential hypertension (EH). In one study, 2 researchers searched and extracted 7 databases for systematic reviews (SRs) and meta-analyses (MAs), and independently assessed the methodological quality, risk of bias, reporting quality, and quality of evidence of RCTs included in the SRs/MAs.22 This overview included 14 SRs/MAs that use quantitative calculations to comprehensively assess the various effects of acupuncture in EH interventions. The methodological quality, reporting quality, risk of bias, and quality of evidence for outcome measures of SRs/MAs were all unsatisfactory. The conclusions drawn were that, currently, acupuncture may be an effective and safe treatment for EH, but the quality of evidence is low. The authors also concluded that caution should be exercised when applying this evidence in clinical practice.
Conclusion
Acupuncture seems to have fewer side effects and adverse effects than other forms of therapy. Nevertheless, regardless of how low the risk, patients should be informed of the extremely low risks of infection, minimal pain at the needling site, and occasional stiffness. Its effectiveness in a wide realm of conditions is variable. Although there are many innovative studies, the quality is generally low and numbers insufficient to make sweeping treatment changes. Nevertheless, when other therapies prove inadequate, acupuncture may offer some relief, especially in combination with established treatments.
Next month, in part II of this series (September 2023; 39:2), we will cover the use of acupuncture in treating other diseases and conditions, including the following areas:
* Pediatrics, such as attention and learning disorders, autism spectrum disorders, and cerebral palsy and muscle dystonia
* Dentistry, including root canal treatment, endodontic treatment, procedure anxiety, and paresthesia and facial paralysis
* Cognitive function and head pain, including insomnia and tension-type headache.
* Fibromyalgia
* Tinnitus
We also will discuss miscellaneous conditions for which acupuncture has been tried and studied, including eczema, uremic pruritus, sexual function, prostatitis, sleep apnea, and pain after thalamic stroke; the use of acupuncture in veterinary medicine; artificial intelligence as applied to acupuncture research and training; and reported adverse effects.
References