The safety of acupuncture
BMJ 2001; 323 doi: https://doi.org/10.1136/bmj.323.7311.467 (Published 01 September 2001) Cite this as: BMJ 2001;323:467All rapid responses
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Sir,
Vincent in his editorial [1] was right to point out that the two
studies on the safety of acupuncture are reassuring.[2,3] He also pointed
out that considering safety alone is unhelpful, a risk: benefit ratio
should be considered. However, harm comes not only from adverse events.
Another area of concern with "alternative" practitioners is the lack of
communication with "conventional" carers, and in particular primary care.
If one core element of primary care is co-ordination of care [4] then poor
communication between complimentary practitioner and primary care can only
serve the patient poorly. Indeed, harm may occur. Without full knowledge
of the patient, their condition and medications inadvisable treatments
might be advocated. Therefore there needs to be a clear link between
"alternative" or, better still, complementary practitioners and the
patients primary care provider.
To create a linkage between primary care provider and complementary
therapist does require a different approach. In our own practice we have
forged strong links with a chiropractic doctor (in the past, placing a
fund holding contract with one), offered accommodation to an acupuncturist
and have held evening meetings with complimentary therapists to discuss
the merits of their treatments. Two partners in the practice are trained
in the basics of complementary therapies (acupuncture and homoeopathy).
All this adds up to an open relationship between patient, their GP and
their complementary therapist. One area that we have not succeeded with is
in linking with herbalists. This is of some concern given the possible
interactions between herbal remedies and allopathic treatment [5] and the
potential problem of herbal toxicity that may not be recognised for what
it is [6].
Therefore safety studies of complementary therapy needs to look at
broader aspects of care and, in particular, communication and
organisational problems that might arise.
Tim Wilson
1 Vincent C. The safety of acupuncture. BMJ 2001; 323: 467-468.
2 White A, Hayhoe S, Hart A, Ernst E. Adverse events following
acupuncture: prospective survey of 32 000 consultations with doctors and
physiotherapists. BMJ 2001; 323: 485-486.
3 MacPherson H, Thomas K, Walters S, Fitter M. The York acupuncture safety
study: prospective survey of 34 000 treatments by traditional
acupuncturists. BMJ 2001; 323: 486-487.
4 Starfield B. Primary care: balancing health needs, services and
technology. Oxford: Oxford University Press, 1998.
5 Braun L. Herb-drug interaction guide. Aust Fam Physician 2001: 30(6):
581-2
6 Borins M. The dangers of using herbs. What your patients need to know.
Postgrad Med 1998; 104(1): 91-5, 99-100
Competing interests: No competing interests
My personal conclusions:
1. Acupuncture does not need a physician`s education.
2. Acupuncture is safe, but expensive.
3. There is a need to save money and the healthiness of poor people in
Public Health Systems.
4. Acupuncture should not be paid by PHS as a physician`s task, but like
other physiotherapies. And these therapies only in case there is no
cheaper treatment with comparable safety and efficacy.
Competing interests: No competing interests
Attributable Risk a better concept than Adverse Effect
Elsewhere I've written how problematic it is to define let alone
quantify adverse events associated with acupuncture.
http://www.medicalacupuncture.org/aama_marf/journal/Vol11_2/adverse.html
I think this is echoed to some degree in this article by Vincent. He
like so many others have left out an issue I think needs highlighting: if
one understands the principles behind traditional forms of acupuncture,
the notion of an adverse event becomes problematic. As we attempt to
utilize the same terminology and methodology that has been applied to
pharmaceutical and specific surgical interventions -- with acupuncture
practiced in a traditional manner -- we are going to encounter problems.
In Western thought, if the result is anything but its intended result,
then it is an adverse event or side effect. This is the result of linear
reasoning. Linear reasoning does not translate well to acupuncture based
on Oriental contextual models. For example, a patient receives acupuncture
for neck pain with the only immediate result a sense of deep relaxation.
Our Western paradigm would equate the relaxation with an adverse event
(Relaxation has been actually termed an adverse event in some reviews)
However, from a contextual Oriental Medical approach, if the patient
learns to relax, then over time, his neck pain may improve. So that
relaxation would not be defined as an adverse event, but a salutary effect
of the acupuncture. This may appear as mere semantics. Clinical
implications could however, be significant. Patients may well halt
treatment or be unnecessarily concerned if they develop symptoms other
than those anticipated especially if we convey to patients that all
unexpected/unwanted events are adverse. We can still help patients
evaluate the risks associated with acupuncture by outlining the estimated
attributable risk of such events. In my opinion, this meets the ethical
challenge of providing informed consent. However, this is pragmatically
moot; standards of practice dictate that unless the attributable risk of a
serious event to a procedure is relatively high (greater than 1 in 500),
one is not obliged to discuss it with the patient. For example, we do not
require informed consents for drawing blood despite the possibility of
fainting, bruising, and even infection except, perhaps, in those cases
where the risk is high such as in a post-mastectomy patient. I believe
that given the low incidence of serious adverse events associated with
acupuncture, a formal informed consent is not indicated.
I think if we continue to use the same terminology and methodology to
evaluate acupuncture as we do pharmaceutical agents, we neither understand
classically applied acupuncture or the limits of our standard Western
methodologies.
Also I want to comment briefly about some colleagues questioning the
benefits of acupuncture. It's obvious the benefits of acupuncture are
significant, now to what degree they have to do with specific needling
techniques or some enhancement of the placebo effect this all needs to be
worked out. I just think it is ludricous for intelligent and/or informed
individuals to deny the possible significant benefits to patients who are
cared for by a qualified acupuncturist. Since it is a surgical procedure
I also vote to involve physicians in it's delivery.
Competing interests: No competing interests