Am Fam Physician. 2019;100(2):76-78
Related letter: Acupuncture Not Supported by Strong Scientific Evidence
Author disclosure: No relevant financial affiliations.
In traditional Chinese medicine, pain has been treated with acupuncture for more than 2,500 years.1 Yet, only in the past 20 years has acupuncture's effect on pain been studied in Western medicine.2 In this issue of American Family Physician, Kelly and Willis provide an update on the evidence for acupuncture to treat pain.3 Although current research demonstrates the effectiveness of acupuncture, both patients and physicians have preconceived notions about what acupuncture is and what it can accomplish, making it challenging to incorporate the therapy into family medicine practice.
We have studied physician and patient perspectives on the implementation of medical acupuncture in the military health system using the RE-AIM framework,4 which prompts five questions: (1) Reach: how do we reach patients with medical acupuncture? (2) Efficacy: does medical acupuncture affect patient outcomes? (3) Adoption: how do we build clinical and organizational support to deliver acupuncture to patients? (4) Implementation: is medical acupuncture implemented consistently across clinics? (5) Maintenance: how will this intervention be sustained in the long term?
Family physicians must not only know that acupuncture is an option but also feel confident in providing it for patients, making training critical. In our research, multiple physicians acknowledged biases and suspicions before training about the validity of acupuncture, describing acupuncture as voodoo, hippie stuff, or quackery. But, training-related turning points shifted their perspective by providing them with evidence that validated acupuncture is an effective medical practice. Our research also shows that acupuncture training is linked to lower opioid prescribing and less depersonalizing of patients.5–7
Communicating with the patient about acupuncture follows three key steps: introduce the concept, explain the medical process, and evaluate treatment outcomes.8 To introduce acupuncture, physicians need to initiate the discussion, use a collaborative communication style, and mention treatment effectiveness. Physicians should tell patients what to expect, including what happens when acupuncture is administered. To evaluate treatment outcomes, physicians must communicate with patients during and after treatment, and at follow-up appointments.
To assess outcomes, physicians and patients should identify complex, interrelated health outcomes (as opposed to simply eliminating a physical symptom, such as pain), including better sleep, improved mental health, and improved quality of life.9 Measuring the effectiveness of acupuncture as a pain treatment presents a challenge to some physicians who are accustomed to a laboratory value or radiograph that can demonstrate positive results. The success of acupuncture treatment, like most treatments for pain, relies on patient report, which requires the physician to engage the patient in a clear discussion of patient outcomes. Physicians can use the traditional pain scale, asking patients to rate their pain with a number. Physicians should also ask patients about improvements in function, sleep, and mood.
Barriers to implementing acupuncture in the clinic include patient aversion to needles, time and scheduling constraints, lack of clinic space, and inadequate resources.9 Still, patients will often work to overcome barriers when they prefer a treatment alternative with a low risk of adverse effects or when debilitating pain has not responded to other treatments.9 Strategies that can increase adoption of acupuncture include shared decision-making; patient-centered communication, including not pushing the patient, carefully choosing language, explaining treatment outcomes, and being responsive to the patient; and continuity of care (one physician interacting with the patient across treatment).10 Table 1 presents sample language for these strategies.8–10
|Shared decision-making fosters comfort and collaboration between patient and physician|
|Present options||“We can try physical therapy, or we can try bracing. Another option that's available here is acupuncture. We're incorporating it more into our clinic.”|
|Explain risks and benefits||“I think acupuncture may help you. I've noticed in my own patients that it seems pretty beneficial. Eighty percent of my patients get better with acupuncture or have a positive response.”|
“Acupuncture is ideal for avoiding adverse effects of medications and returning people to work without impairment.”
|Encourage patient reflection||“What are your thoughts on those options?”|
“What would you like to do?”
|Be careful not to push the patient when offering information or attempting to overcome the patient's fear of needles||“There are more options available, but I recommend acupuncture. I use it on myself and my family to try to help with pain and discomfort.”|
“If you're uncomfortable with needles, let's try one needle in one point. Then we can talk about if you want to keep going.”
|Make conscious wording choices|
|Avoid technical terms||Instead of: “I'm going to stick the needle in your Gall Bladder 41, and then I'm going to take this into Spleen 6.”|
Try: “This is a treatment where we just try to center your thoughts around calmness.”
|Avoid words with negative connotations||Instead of: [when describing needle insertion] “This might hurt.”|
Try: “These are strong points. These are more powerful points.”
|Carefully use or avoid traditional Chinese medicine terms||Instead of: “We're going to try a treatment called dragons, in which we move your energy to remove the demons.”|
Try: “The acupuncture treatment is going to help settle your body and your mind.”
|Explain potential acupuncture outcomes, not just effectiveness|
|Clarify when to expect an effect||“If you get any response, that's good. Eventually, I want to get you spaced out to three to four months, so you're coming in for a maintenance treatment.”|
“Acupuncture is like unlocking a door. To unlock a locked door, first you have to pick up the key. That's your first appointment. Then you have to actually move toward the door, and that's your second treatment. You have to put the key in the door. That's your third treatment. Turn it, fourth; turn the handle, fifth; open the door, sixth; walk through, seventh. That's how acupuncture works—you're not going to see one treatment be a miracle. It's a stepwise process.”
|Warn patients about a potential emotional response||“It's probably because you've been out of balance for awhile, and it feels uncomfortable to try and push you back into that equilibrium. That's okay if you feel bad for the first couple of days. It will get better. Any kind of a change is a good sign, because it means that we did something to activate that and to improve that for you.”|
“This may make you cry. This may make you laugh. I don't know what will happen, but it's not uncommon for emotions to process, and you to start to feel something during that time period when you're getting therapy.”
Another potential barrier to the broad adoption of acupuncture is cost. In private primary care practice settings, we have found that acupuncture sessions can cost from $70 to $150, and few insurance companies reimburse for acupuncture procedures.
Acupuncture is an evidence-based therapy to reduce pain that can meet patient demand for nonpharmacologic treatment. Now is the time to offer training in medical acupuncture to more family physicians. This will require an enhanced understanding of how to implement these old, but new, treatments in family medicine and how to engage patients to manage their pain with this modality.
The authors thank Carla L. Fisher, PhD, and all of the family physicians who have participated in their research.
The opinions and assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the U.S. Air Force, the Uniformed Services University of the Health Sciences, or the Department of Defense at large.