Evidence-based approach to acupuncture in integrative medicine for pain management Zhen Zheng BMed, PhD(Melb) WHO Collaboration Centre for Traditional Medicine, TCM Research Program, Health Innovations Research Institute, & Discipline of Chinese Medicine, School of Health Sciences, RMIT University, Melbourne, Australia

How does acupuncture work?

Outline Multidimensional aspects of musculoskeletal pain Three problems of current pain management Acupuncture in pain management and evidence Strengths, weaknesses and current status How to use acupuncture in integrative medicine

Multidimensional aspects of musculoskeletal pain Inactivity Muscle Wasting Fatigue Depression Pain & Disability Lack of sleep Anxiety Anger Restless- ness Fear Family issues Social and financial aspects Physical functioningMental functioningSocial functioning

Comorbidity of chronic musculoskeletal pain (Lu, Zheng, et al 2010) Slide deleted. Unpublished data.

Pain management Problem 1: Overuse of medications (Pain and Policy Studies Group 2007) Increased by 8 times Morphine Increased by 20 times Oxycodone

Problem 2: Lack of long term benefit (Jensen et al 2006 Eur J Pain 10: ) Patients who were still on morphine medications 10 years after a pain management program had poorer QoL, were more depressed, and adopted passive strategies for pain management.

Problem 3: High cost (ABS 2004) In Australia, the cost of health conditions Cardiovascular diseases (11.2% of total allocated health care) Nervous system diseases (9.9%). Chronic musculoskeletal conditions (9.5%)

Does acupuncture have the answer? can reduce the use of pain medications ； provides long term relief (chronic pain) ； and is cost-effective? What can acupuncture do for chronic pain? Is there any evidence supporting that acupuncture

Level of evidence (Results of some studies are more reliable and valid than those of others.) SR of RCTs RCTs Controlled trials Uncontrolled data (case reports and series) Experts’ opinions Adapted from Ernst, E (1999) Classic literature Clinical experience Cases Clinical studies Animal studies

Acupuncture for pain ( NIH 1998; JAMA 280: ; WHO 2002) World Health Organization (WHO) and National Institute of Health (NIH) of USA Post-operative pain Musculoskeletal pain Headache Fibromyalgia.

Acupuncture for postoperative pain: Pain (1) (Sun et al 2008 Br J Anaesth 101(2):151-60) Pain reduction: Acu > standard therapy at 8 and 72 hours, but not at 24 hours.

Acupuncture for postoperative pain: opioid medication use (2) (Sun et al 2008 Br J Anaesth 101(2):151-60) Opioid medication use: Acu < sham Acu. Lesser as postoperative period extends.

Acupuncture for postoperative pain: Nausea and vomiting (3) (Lee et al 2004 Cochrane)

Acupuncture for postoperative pain: Australian position (4) (Macintyre et al 2010) Acute Pain Management: Scientific Evidence. 3 rd edition. Compiled by the Australian and New Zealand College of Anaesthetists, endorsed by NHMRC Level 1 evidence (new) Acupuncture reduces postoperative pain as well as opioid ‐ related adverse effects.

Acupuncture for chronic pain: German ARC, ART and GERAC trials ARC: Randomized, comparative study (acu vs non acu) (n = 50,000) ART: acupuncture, randomized trial (acu vs sham acu vs wait list) (n= 1,200) GERAC: German acupuncture trials (acu vs sham acu vs standard therapy) (n = 2,718) ASH: cohort study (n=300,000)

Acupuncture for chronic pain: response rate ConditionReal Acu (GERAC ART) Sham Acu (GERAC ART) Standard therapy (GERAC) Wait list (ART) OA in the knee53.1% 52% 51% 28% 29.1%3% Low back pain47.6% 54% 44.2% 37% 27.2%13% Migraine47% 51% 39% 53% 40%15% TTH33% 46% 27% 35% Discontinued (amitriptyline) 4%

Acupuncture for persistent non-specific low back pain: UK and USA position National Institute for Health and Clinical Excellence (NICE, UK) Clinical Guideline (2009) Offer one of the following treatment options, an exercise program, a course of manual therapy or a course of acupuncture. American Pain Society Clinical Practice Guideline (Chou 2007 Ann Inter Med 147:478-91). Recommendation 7: For patients who do not improve with self-care options, clinicians should consider the addition of nonpharmacologic therapy with proven benefits… for chronic or subacute low back pain, … acupuncture ….

Acupuncture for low back pain: Australian position on cost-effectiveness (NICM 2010) As a complement therapy to standard care, acupuncture is a very cost-effective therapy.

Acupuncture for chronic pain: Reduces opioid medication use: A RCT (Zheng et al 2008 EJP 12:671-6) 39% reduction 25% reduction

Acupuncture for chronic pain: reduces the use of pain medication – A SR (zheng et al to be published) Slide deleted. Unpublished data.

Acupuncture for chronic pain: Quality of life- improves physical functioning- A SR (Lu, Zheng et al 2010 ECAM)

Acupuncture for chronic pain: QoL- a delayed effect on mental functioning – a SR (Lu, Zheng et al 2010 ECAM)

Electroacupuncture improves global well- being of FM patients (Deare, Zheng et al, a Cochrane review, under review) Slide deleted. Unpublished data.

Acupuncture for pain management: strengths Strong evidence supports A short-term effect of acupuncture for pain, physical functioning and use of medications; Multidimensional effect Sleep, fatigue, well-being Being recognized by key health regulatory bodies in the western countries

MRI imaging of the brain during acupuncture Green – decreased activityRed/yellow-increased activity (Wu, MT et al 1999) Limbic system Hy-hypothalamus; Nac-Nucleus accumbens; NA-amygdala; SMA-supplementary motor cortex; MI-primary motor cortex) Real Acu Sham Acu

Long-term: increased MOR binding potential in Real acu group the temporal pole The dorsal anterior cingulate cortex the perigenual anterior cingulate cortex

How to integrate acupuncture into modern pain management?

Example 1– Acupuncture for tension type of headache (TTH): evidence Acupuncture CBT Reduction of TTH days (%) Weeks in therapy 6 weeks12 weeks3 months after treatment

Example 1 – Acupuncture for (TTH): combined therapy – RMIT is completing an NHMRC funded trial Acupuncture CBT Combined Weeks in therapy 6 weeks12 weeks3 months after treatment Reduction of TTH days (%)

Example 2: Acupuncture reduce opioid medications use – RMIT is completing an NHMRC funded trial Using Electroacupuncture to Reduce the use of opioid medication Reduce the side effects Reduce the withdrawal symptoms

Multidimensional aspects of musculoskeletal pain Inactivity Muscle Wasting Fatigue Depression Pain & Disability Lack of sleep Anxiety Anger Restless- ness Fear Family issues Social and financial aspects Physical functioningMental functioningSocial functioning

Thank you! Questions? Acknowledgements RMIT Pain research team Prof Charlie Xue Dr Yanyi Wang Jessica Guo John Deare David Lu Alan Hao Our collaborators Prof Robert Helme; Prof Stephen Gibson-Uni Melb Prof Paul Martin; A/Prof Geoff Littlejohn – Monash Dr Carolyn Arnold – Caulfield Dr Malcolm Hogg – RMH