How are some family physicians treating one of the biggest public health problems of the past 25 years?
With a form of healing that has been practiced for millennia.
Since the mid-1990s, the opioid epidemic has resulted in the deaths of tens of thousands of Americans(www.drugabuse.gov) and created an economic burden that, according to some estimates, now totals more than $78 billion per year.(www.ncbi.nlm.nih.gov) In response, family physicians and other health care professionals are using every tool at their disposal to fight the epidemic, including what some consider a promising -- albeit surprising -- therapeutic protocol.
In a letter(academic.oup.com) published online in the journal Pain Medicine, three researchers, including one member of the Uniformed Services AFP (USAFP), presented findings that showed an association between opioid prescriptions and acupuncture training when managing patients with chronic noncancer pain. The authors found that family physicians trained in acupuncture prescribed fewer "strong" opioids such as oxycodone and fentanyl than did FPs without training. And, in fact, those with more advanced acupuncture training prescribed far fewer opioids overall after their training than they did before.
- Recent results from a survey of Uniformed Services AFP members suggest an association between training in acupuncture and opioid prescriptions for patients with chronic noncancer pain.
- The survey found that family physicians who received training in acupuncture prescribed fewer opioids for patients, especially "strong" opioids such as oxycodone and hydrocodone.
- The survey report authors suggested that acupuncture training could potentially improve patient care while reducing some health care costs.
"Research continues to highlight that nonpharmacologic treatments such as acupuncture may provide benefits to some patients," said Julie Wood, M.D., M.P.H., AAFP Senior Vice President for Health of the Public, Science and Interprofessional Activities. "Given the effects of the ongoing opioid epidemic on pain management, nonpharmacologic options are important in helping patients manage pain."
Study Methods and Findings
The authors reviewed data from the USAFP's Clinical Investigations Committee, which sent a survey to all physicians who registered to attend the USAFP's 2017 Annual Meeting & Exposition. The survey asked physicians to provide demographic information and to indicate whether they had no acupuncture training or had completed training in auricular acupuncture (a 20-hour course with an emphasis on stimulation of points on and around the ear) or medical acupuncture (a more comprehensive course spanning 220 or more hours of training on multiple forms of acupuncture).
In addition, physicians were asked a series of questions about their opioid prescribing habits, along with queries about how often they used or recommended nontraditional therapies such as nutrition, acupuncture and massage.
Specifically, participants were asked to estimate, averaged over the previous three months, the number of patients per month for whom they had written a prescription for either "weak" (codeine, meperidine, pentazocine, propoxyphene or tramadol) or "strong" (fentanyl, hydrocodone, hydromorphone, methadone, morphine or oxycodone) opioids for chronic noncancer pain. Those responses were then correlated with the respondents' self-reported acupuncture training status.
The researchers found no significant difference between family physicians with no acupuncture training and those with any level of training when it came to the number of patients prescribed weak opioids for chronic noncancer pain.
There was, however, a difference when it came to prescribing strong opioids. More than 5 percent of family physicians with no training in acupuncture reported that on average, they wrote prescriptions for strong opioids for 11 or more chronic noncancer pain patients each month. In comparison, only 2 percent of family physicians trained in auricular acupuncture and no physicians trained in medical acupuncture said they wrote prescriptions for strong opioids for that many patients per month.
At least some proportion of physicians in both acupuncture groups also reported prescribing fewer opioids overall after receiving acupuncture training. One-sixth of family physicians in the auricular acupuncture group and more than 77 percent of FPs in the medical acupuncture group agreed or strongly agreed with the statement that they currently prescribed fewer opioids than they did before learning acupuncture.
Finally, acupuncture training was associated with an overall preference for nontraditional pain management therapies. Every family physician in the medical acupuncture group and 80 percent in the auricular acupuncture group reported that they often or always preferred using nontraditional therapies to manage pain, compared with 66 percent of those with no acupuncture training.
Implications for Family Physicians
Based on these findings, the authors suggested that training family physicians in acupuncture could serve several purposes related to improving care and reducing costs.
First, it would facilitate FPs' ability to implement a stepped care model for pain management.
Second, it would provide a nonaddictive and relatively inexpensive alternative to opioids, which would reduce the risk of opioid abuse and misuse.
Third, by delivering acupuncture in the office, it would save the administrative time and hassle associated with referring a patient off-site and reduce the possibility of care being fragmented.
Noting the self-reporting and other limitations of their study, the researchers recommended that future studies be conducted to better quantify the links between acupuncture training and opioid prescription rates.
Although the AAFP does not have specific policy on acupuncture, it has endorsed the low back pain guideline developed by the American College of Physicians, which includes acupuncture as one of several nonpharmacologic treatment options to be used initially for most patients with acute, subacute or chronic low back pain.
Wood told AAFP News that although many family physicians are open to alternative therapies such as acupuncture, guidance about the efficacy of these treatments is indicated.
"Training in the benefits, harms and indications is important," she said.
For the past several years, the AAFP has offered a clinical procedure workshop on acupuncture and manipulation techniques for pain management at the annual Family Medicine Experience conference.
In addition to the AAFP's training offerings, other training opportunities are offered by the American Academy of Medical Acupuncture,(www.medicalacupuncture.org) an organization whose founding president, Joseph Helms, M.D., is a practicing family physician.
For family physicians who do not offer acupuncture, Wood recommended that they become familiar with health care professionals in their area who provide such services in case patients need to be referred for care.
"The number of family physicians trained in medical acupuncture is low," Wood said. "As a result, patients seeking acupuncture will most likely be referred out for this treatment. It is important to know who in the community provides quality acupuncture and what conditions they treat before referring patients."
Related AAFP News Coverage
Research Finds Acupuncture Effective for Chronic Pain
FP Essentials: Musculoskeletal Therapies
The Joint Commission: Quick Safety 44: Non-pharmacologic and Non-opioid Solutions for Pain Management(www.jointcommission.org)