Acupuncture: Health benefits of acupuncture What is acupuncture Explain for what acupuncture started to be used When started to use acupuncture in health? (Pap3r 2) 2. Pain

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Acupuncture integrative therapy for oioids epidemic LCM

Article · October 2019

DOI: 10.21037/lcm.2019.09.05

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The loss caused by opioids epidemic in the United States

In the United States, it was estimated that in 2016, about 25 million residents suffered from various chronic pain, while 126 million adults had certain type of pain in the prior three months (1). US Centers for Disease Control and Prevention (CDC) based on National Health Interview Survey (NHIS) Data in the same year and pointed out that there were 50 million (20.4%) adults with chronic pain and about 20 million (8.0%) adults with high-impact chronic pain, especially among women and older adults (2). As a result, 216 to 255 million prescriptions per year were written for opioid medications during 2006 to 2016, which is about 66.5–82.1 prescriptions per 100 residents, while 191 million prescriptions were written (or 58.7 per 100 residents) in 2017 (3). Such over-prescription of opioids also includes some illegal prescriptions by healthcare providers, although the reasons for this and the opioid epidemic have been complicated. For example, federal prosecutors charged 60 doctors, pharmacists, medical professionals and others in connection with alleged opioid pushing and health care fraud (4). An unfortunate consequence of this high use and availability of opioids is a growing number of opioid- related deaths from addiction and overdose. There were 70,237 drug overdose deaths that occurred in the United States in 2017, while opioids—mainly synthetic opioids (other than methadone)—alone caused 47,600 deaths (equal to 130 deaths per day, occupying 67.77% of total overdose deaths). This is a 12.9-fold increase from 2007 to 2017 (5). CDC estimates that the total “economic burden” of prescription opioid misuse alone in the United States is

at least 78 and half billion dollars a year, including the costs of healthcare, lost productivity, addiction treatment, and criminal justice involvement; equal to each United States resident spending $248.26 per year for this loss (6).

Reactions of United States government agencies

The opioids epidemic has been so severe, as to a White House panel urged the United States president to declare the opioid crisis a national emergency, and August 31 of each year was designated as “International Overdose Awareness Day” by the CDC (7). To solve the opioid crisis, various federal regulatory and oversight agencies, issued various plans and strategies in solving such epidemic. For example, the United States Food and Drug Administration (FDA) developed a comprehensive action plan to take concrete steps toward reducing the impact of opioid abuse on American families and communities. As part of this plan, the agency is planning to work more closely with its advisory committees before making critical product and labeling decisions; enhancing safety labeling; requiring new data; and seeking to improve treatment of both addiction and pain (8). The National Academies of Sciences, Engineering, and Medicine (NASEM), issued National strategy to reduce the opioid epidemic, an urgent public health priority (9), and the Joint Commission-the accreditation agency for United States healthcare system especially for hospitals— have started to advise or mandate that healthcare systems and providers offer non-pharmacologic treatment options for pain control (10).

As one of non-pharmacological therapies, acupuncture

Editorial Commentary

Acupuncture: an integrative therapy for pain management and opioid reduction in the United States

Arthur Yin Fan1,2, Sarah Faggert Alemi1,3

1American TCM Association, Vienna, VA, USA; 2McLean Center for Complementary and Alternative Medicine, PLC., Vienna, VA, USA; 3Eastern

Roots Wellness, PLC, McLean, VA, USA

Correspondence to: Arthur Yin Fan, MD, PhD, LAc. American TCM Association, 8214A Old Courthouse Road, Vienna, Virginia 22182, USA. Email:

[email protected]

Received: 06 August 2019. Accepted: 23 September 2019.

doi: 10.21037/lcm.2019.09.05

View this article at: http://dx.doi.org/10.21037/lcm.2019.09.05

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is the most evidence-based, immediately available choice to fulfill these calls for addiction treatment and pain management. It has been frequently recommended because it has a special role in resolving the opioid epidemic in the United States either by treating the pain and decreasing opioid usage, or by treating opioid addiction itself (11). On June 19, 2018, Rep. Jackie Walorski and Rep. Judy Chu’s Opioid Alternative Bill passed unanimously in the United States Congress, in which acupuncture is one of the major alternatives for prescription pain medication. On Oct 24, 2018, President Trump signed the historic Opioid Package H.R.6 Act (Support for Patients and Communities Act, also known as Substance Use—Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities Act) into law, in which above- mentioned Opioid Alternative Bill was included. Both the House and the Senate overwhelmingly passed this final package which included in acupuncture as one of important integrative methods in pain management and solving opioid epidemic (12). It is very encouraged for United States acupuncture and Chinese medicine professionals- since our American TCM Association (ATCMA) is one of sponsor organizations for Rep. Judy Chu’s acupuncture bills.

Since 2018, Veteran Administration started to cover acupuncture for all military veterans and their family members (13), although Tricare for military service members, etc. still does not cover acupuncture until now (14). Following the requirements of H.R.6 law, Medicare planned to implement step-by-step to cover acupuncture for seniors and disabled people. As the first step, for further assessing acupuncture’s effect, Medicare together with National Center for Complementary and Integrative Medicine (NCCIH), National Institutes of Health (NIH) initiated a large pragmatic acupuncture trial on chronic low back pain in seniors (15). It is one year and another three years, two steps study. It can be expected that Medicare will have real steps toward cover the acupuncture, and it is important in decreasing the opioids usage in seniors and disabled populations.

Update in acupuncture professions

In 2016, National Cancer Institute (NCI) held a special conference and after that NCI officials and experts published a White Paper on acupuncture for symptom management in oncology which had been collected by Rand as known United States thinking tank for helping address some of the world’s most challenging problems, it urges

the transformation of acupuncture research into cancer symptom management (16,17). Currently, acupuncture has been used in most leading United States—based cancer centers as one of the major integrative medicine therapies in cancer care—in treating the various cancer related pains or other symptoms, and decreasing the usage of opioids medications. In 2018, NCI held its second conference on Acupuncture for Symptom Management in Oncology, together with NCCIH. It is clear that NCI and NCCIH have very strong desire in acupuncture development and pushing its applications in main medical stream, encouraging the transforming of acupuncture research results into real clinical practice.

Thirteen organizations and academic institutions in the United States acupuncture professions, Chinese medicine and main stream academic institutions published a White Paper in late 2017, to summarize for academic scholars, healthcare professionals, administrators, policymakers, and the general public the available evidence for acupuncture as a treatment for various pain conditions as well as for opiate addiction. It included evidence on the safety, cost-effectiveness, mechanisms of actions, and provider availability for acupuncture (11). It has been widely spread among Congress members, and various organizations and agencies, as well in academic field, it already got more than 20 citations during one and half year. Kong from society for acupuncture research (SAR) also published article and called for exploring the multiple roles of acupuncture in alleviating the opioid crisis (18). Both articles consider that acupuncture is an effective, safe, and cost-effective treatment for numerous types of acute and chronic pain; it should be listed as a first line treatment for pain before opiates are prescribed, and may reduce opioid usage. Its analgesic mechanisms have been extensively explored and acupuncture can increase the production and release of endogenous opioids in both animals and humans. It is effective for the treatment of various chronic pain conditions involving maladaptive neuroplasticity. A c u p u n c t u r e i s a v e r y p r o m i s i n g , a l r e a d y a p p l i e d adjunctive therapy in opiate addiction and rehabilitation. As most commonly recommended, non-pharmacological management options for pain relief, evidence supports acupuncture is the most specific and effective for opioid abuse and overuse. Acupuncture is widely available from qualified practitioners nationally; there are more than 37,000 licensed acupuncturists and over 10,000 medical acupuncturists in the United States in 2018 (11,19).

ATCMA has been formed by acupuncture and Chinese

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medicine providers graduated from Universities or Colleges of Chinese Medicine. Its members have actively involved in acupuncture research and advocate in the UNITED STATES (11,16,19). Recently ATCMA members followed Medicare and NCCIH research guideline and involved in clinical study on real-world acupuncture treatments for chronic low back pain in older adults (20). They further collaborated with members of SAR, formed a research team, and submitted research proposal to NCCIH in March 2019. In this big project, current author (Arthur Yin Fan) has served as one of three research consultants. No matter whether get the grant or not, ATCMA and its members will continue working on promote acupuncture, as one form of integrative non-pharmacological therapies in treating the pain, decreasing opioids usage and solving opioids epidemic.

Acknowledgments

This paper was written and revised on the basis of original work of White Paper serials by the American TCM Association.

Footnote

Conflicts of Interest: The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

References

1. United States National Center for Complementary and Integrative Medicine, National Institutes of Health. NIH analysis shows Americans are in pain. (2015-08- 11). Accessed on August 3, 2019. Available online: https:// nccih.nih.gov/news/press/08112015

2. Dahlhamer JD, Lucas J, Zelaya C, et al. Prevalence of Chronic Pain and High-Impact Chronic Pain Among Adults — United States, 2016. MMWR Morb Mortal Wkly Rep 2018:67;1001-6.

3. Centers for Disease Control and Preventions. United States Opioid Prescribing Rate Maps. Accessed on August 3, 2019. Available online: https://www.cdc.gov/ drugoverdose/maps/rxrate-maps.html

4. Johnson C. Nearly 60 Doctors, Other Medical

Workers Charged In Federal Opioid Sting. Accessed on August 2, 2019. Available online: https://www.npr. org/2019/04/17/714014919/nearly-60-docs-other- medical-workers-face-charges-in-federal-opioid-sting

5. National Institute on Drug Abuse, National Institutes of Health. Overdose Death Rates (Revised January 2019). Accessed on August 3, 2019. Available online: https://www. drugabuse.gov/related-topics/trends-statistics/overdose- death-rates

6. Florence CS, Zhou C, Luo F, et al. The Economic Burden of Prescription Opioid Overdose, Abuse, and Dependence in the United States, 2013. Med Care 2016;54:901-6.

7. Centers for Disease Control and prevention. International Overdose Awareness Day — August 31, 2018. MMWR Morb Mortal Wkly Rep 2018;67:945.

8. United States Food and Drug Administration. FDA Opioids Action Plan. Accessed on August 3, 2019. Available online: https://www.fda.gov/drugs/information- drug-class/fda-opioids-action-plan

9. The National Academies of Sciences, Engineering, and Medicine. National strategy to reduce the opioid epidemic, an urgent public health priority, presented in new report. (2017-07-13). Accessed on August 2, 2019. Available online: https://www.sciencedaily.com/ releases/2017/07/170713154825.htm

10. Official Publication of Joint Commission Requirements. New and revised standards related to pain assessment and management. Jt Comm Perspect 2017;37:3-4.

11. Fan AY, Miller DW, Bolash B, et al. Acupuncture's Role in Solving the Opioid Epidemic: Evidence, Cost- Effectiveness, and Care Availability for Acupuncture as a Primary, Non-Pharmacologic Method for Pain Relief and Management-White Paper 2017. J Integr Med 2017;15:411-25.

12. White House. President Donald J. Trump Signed H.R. 6 into Law. Issued on October 24, 2018. Accessed on August 3, 2019. Available online: https://www.whitehouse.gov/ briefings-statements/president-donald-j-trump-signed-h- r-6-law/

13. Postolov L. No-Cost Acupuncture Treatments for Military Veterans and their Families. Accessed on August 3, 2019. Available online: https://nvf.org/no-cost-acupuncture- treatments-military/

14. TriCare. Acupuncture. Accessed on August 3, 2019. Available online: https://tricare.mil/CoveredServices/ IsItCovered/Acupuncture

15. National Center for Complementary and Integrative Medicine. HEAL Initiative: Pragmatic Randomized

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© Longhua Chinese Medicine. All rights reserved. Longhua Chin Med 2019 | http://dx.doi.org/10.21037/lcm.2019.09.05

Controlled Trial of Acupuncture for Management of Chronic Low Back Pain in Older Adults (UG3/UH3 Clinical Trial Required) – Technical Assistance Videocast. Accessed on August 2, 2019. Available online: https://nccih. nih.gov/news/events/webinar/heal-acupuncture-2019

16. Zia FZ, Olaku O, Bao T, et al. The National Cancer Institute's Conference on Acupuncture for Symptom Management in Oncology: State of the Science, Evidence, and Research Gaps. J Natl Cancer Inst Monogr 2017. doi: 10.1093/jncimonographs/lgx005.

17. Rand. External published research. Accessed on September 10, 2019. Available online: https://www.rand.org/pubs/

external_publications/EP67415.html 18. Kong JT. Exploring the Multiple Roles of Acupuncture in

Alleviating the Opioid Crisis. J Altern Complement Med 2018;24:304-6.

19. Fan AY, Stumpf SH, Faggert Alemi S, et al. Distribution of licensed acupuncturists and educational institutions in the United States at the start of 2018. Complement Ther Med 2018;41:295-301.

20. Fan AY, Ouyang H, Qian X, et al. Discussions on real- world acupuncture treatments for chronic low-back pain in older adults. J Integr Med 2019;17:71-6.

doi: 10.21037/lcm.2019.09.05 Cite this article as: Fan AY, Alemi SF. Acupuncture: an integrative therapy for pain management and opioid reduction in the United States. Longhua Chin Med 2019.

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Physio ‘dry needling’ and acupuncture – what’s the difference and what does the evidence say? Hing, Wayne; McCutcheon, Leigh . Publicación de blog. Daily Maverick [BLOG] , Cape Town: Daily

Maverick. Jul 11, 2022.

Enlace de documentos de ProQuest

TEXTO COMPLETO Acupuncture. Image: Pixy

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By Wayne Hing and Leigh McCutcheon

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Dry needling and Western acupuncture don’t incorporate traditional chinese medicine philosophies – but may be

helpful for pain and releasing muscle tension.

Physiotherapists are increasingly offering needling therapies in addition to their standard care.

Is it just a fad or does science support it?

Needling, three ways

Physiotherapists can be trained to use dry needling, Western acupuncture and/or traditional acupuncture.

Dry needling involves penetrating the skin with needles to altered or dysfunctional tissue in order to improve or

restore function. This often involves needling muscle trigger points to activate a reflexive relaxation of the muscle.

Western acupuncture uses traditional needling meridians (the ancient idea of energy channels through the body)

and trigger points. But these ideas are applied to Western understandings of anatomy. In Western acupuncture,

points are stimulated to create local tissue changes, as well as spinal and brain effects. The goal is to trigger pain-

relieving chemicals, muscle activation or relaxation.

Even though traditional acupuncture points are used with this style of needling, Western acupuncture is not viewed

as traditional Chinese medicine.

Traditional acupuncture uses meridian lines or other points based on traditional Chinese medicine assessment

methods and approaches.

All physiotherapists trained in either acupuncture or dry needling meet safety standards which are viewed as

within scope by the Australian Health Practitioners Regulatory Agency and the Physiotherapy Registration Board.

These standards cover the level of training required, registration to practice and safety standards that include

needle safety and hygiene to protect the public.

Minor reported side effects related to acupuncture including pain and bleeding or bruising from needle insertion

are fairly common. But major adverse events – pneumothorax (collapsed lung), excessive bleeding, prolonged

aggravation – are rare.

What’s needling good for?

Research into the effectiveness of acupuncture and dry needling is variable. Some studies show comparable

results between dry needling and acupuncture, while others show more favourable results for one or the other

depending on the condition being treated.

A review that assessed the effects of acupuncture and dry needling for the treatment of low-back pain found they

may be useful add-on therapies but could not make firm conclusions due to a lack of quality trials.

Another review reported the growing popularity of dry needling world wide and across disciplines and points out

that many questions still remain regarding the use of needling.

For migraine and tension headaches, experts say acupuncture seems to reduce the frequency and intensity of

attacks – though more research is needed to compare it to other treatments.

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Acupuncture and dry needling may reduce pain and improve function for people with neck pain. A systematic

review found significant differences between acupuncture and “sham acupuncture” (which is performed away

from acupuncture points) when used to treat certain types of chronic pain. However, some research only shows

small and temporary relief for neck pain with dry needling.

Results from randomised control trials support the use of needling for shoulder pain, tennis elbow and osteo

arthritic knee pain. But a recent systemic review of research reported only weak evidence to support needling to

treat plantar fasciitis and chronic ankle instability.

Not just for sporting injuries

Similarly, small randomised control trials have shown acupuncture and dry needling might reduce problematic jaw

pain (temporo mandibular disorder) and improve mouth opening.

Systematic reviews have reported needling and acupuncture were safe and effective recommendations for the

treatment of broad conditions of tendinopathy (the breakdown of collagen in tendons) and fibromyalgia (chronic

pain in the muscles and bones).

For women’s health, acupuncture has been shown to be effective for reducing pain with periods, compared to no

treatment or non-steroidal pain relief medications – but the research had design limitations.

Though widely used in pregnancy, research into the use of acupuncture to induce labour reports it may increase

satisfaction with pain management and reduce pain intensity. But it may have little to no effect on the rates of

caesarean or assisted vaginal birth.

In summary, it appears needling techniques – whether dry needling or acupuncture – generally show positive

effects over no treatment or “sham” treatments, but more research and high-quality trials are needed.

Which option is better depends on the nature of your pain, what caused it and how long you’ve had it, writes

@FedUniAustralia‘s Andrew Lavender.https://t.co/xWqk4IjM4U

— The Conversation (@ConversationEDU) September 7, 2021

Just one part of a treatment program

Needling may be useful as part of multimodal care – that is, when more than one treatment is used in conjunction

to treat a problem.

Physiotherapists may combine needling therapies with exercise prescription, hands-on care including massage,

mobilisations and manipulations, and taping techniques. They may also employ therapies that apply external

energy such as ultrasound, laser, transcutaneous (under the skin) electrical nerve stimulation and biofeedback.

Finally, while the various needling techniques all use a filiform needle (with a solid filament as opposed to a hollow

bore needle), the styles with each can be quite different. Ask what style of needling is being employed to treat

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