Stimulated by Hassan et al 2019.
This is a systematic review that asks the question:
Obviously, I needed to look, having recently highlighted a similar topic on the blog: Initial healthcare provider and opioid use in LBP?
The first thing I looked at was to see if there were any papers included that used acupuncture. There were 2 of the 23 included studies on acupuncture: one RCT from 2008; and one retrospective study from 2017.
The RCT was published in the European Journal of Pain, and I did not remember seeing it when it was published. I guess the opioid crisis had not become obvious in 2008, and it was a rather small sham controlled trial (n=35). The intervention involved electroacupuncture (EA) to muscle points in upper and lower limbs twice a week for 6 weeks compared with superficial off point sham EA. Despite being hopelessly underpowered the between group difference in percentage reduction in consumption of opioid like medication (OLM) at the end of the treatment period showed a marked trend in favour of EA (real EA 39% versus sham EA 25%; p=0.056). I am not really interested in the comparison with sham, since we know that acupuncture outperforms sham in the big data in chronic pain. What is more relevant is the practical of use of these techniques in the real world to reduce opioid use.
That brings us to the second paper, a retrospective audit of 172 consecutive patients who received at least 4 sessions of acupuncture over a one-year period at a US military family medicine practice. Medication consumption was compared over a 60-day period prior to being seen for the first time with the same period one year later. The reduction in opioid consumption was 45%.
So that’s not a lot of data, but let’s see what else is in the review.
- Medical cannabis (MC)
- Multidisciplinary (team) interventions (MDT)
- Cognitive behaviour therapy (CBT)
- Opioid tapering support (OTS)
- Mindfullness-orientated recovery enhancement (MORE)
- Therapeutic interactive voice response (TIVR)
- Physical therapy (PT)
So, in short, we have smoking, talking and a bit of touching. Having read this list, my next stop was the methods section of the review to see how IM was defined. How did the authors decide what constituted IM? Well they seem to have simply referred to another paper. This paper seemed to have an appropriate title, but I thought it best to check the full text. The paper is a review article in a journal I remember being referred to as the ‘Yellow Peril’ by a former president of the Royal College of Anaesthetists. For much of its early life this journal sported a yellow cover. I will leave the reader to guess what the peril refers to.
The authors were from Harvard, so that is surely a good sign. Well to cut a long story short, there is no mention of cannabis, or many of the other interventions on the list above. Still, I am not going to be too picky. Afterall, cannabis is surely a herbal product, and since NHS England has banned prescription of herbal medicine on the NHS, it must certainly fall into the category of alternative and therefore also into IM, since the latter is really just proper medicine without leaving out any of the more wacky stuff. That brings us neatly back to cannabis, so I thought I should investigate it a bit more! No, I don’t mean by sampling any, although I did try some canine cannabidiol recently on a veterinary symposium. All I remember was that it stuck to my gums for ages.
Hassan et al included 7 papers on medical cannabis (MC) from 2016 to 2018. The first one listed was a retrospective observational survey of fibromyalgia patients (n=185) using cannabinoids. MC was associated with a 64% decrease in opioid use. This was clearly exciting news, and the same lead author went on to write a lot about MC use in chronic pain. My favourite title from his long list on PubMed is:
Unfortunately the news is not all good for MC, as the same author subsequently found from an online cross-sectional survey (n=989) that high frequency use of MC was associated with worse pain. Furthermore, the lastest prospective study on MC to date did not find any evidence that it improved patient outcomes, or reduced opioid use. Indeed, patients using MC demonstrated lower self efficacy in managing pain.
So it seems that despite the limited evidence, the results for acupuncture appear somewhat better than a lot of the other listed interventions, and of course this is not a competition, we can use combinations. Now we have to find the best and most cost effective combinations, so there is a lot of scope for future research. I think different combinations will suit different environments, and those combinations will often be driven by accessibility and provision. Personnally I quite like the idea of MORE needling with a bit of talking and some simple Tibetan yoga thrown in.
1 Hassan S, Zheng Q, Rizzolo E, et al. Does Integrative Medicine Reduce Prescribed Opioid Use for Chronic Pain? A Systematic Literature Review. Pain Med Published Online First: 22 November 2019. doi:10.1093/pm/pnz291
2 Zheng Z, Guo RJ, Helme RD, et al. The effect of electroacupuncture on opioid-like medication consumption by chronic pain patients: A pilot randomized controlled clinical trial. Eur J Pain 2008;12:671–6. doi:10.1016/j.ejpain.2007.10.003
3 Crawford P, Penzien DB, Coeytaux R. Reduction in Pain Medication Prescriptions and Self-Reported Outcomes Associated with Acupuncture in a Military Patient Population. Med Acupunct 2017;29:229–31. doi:10.1089/acu.2017.1234
4 Lin Y-C, Wan L, Jamison RN. Using Integrative Medicine in Pain Management. Anesth Analg 2017;125:2081–93. doi:10.1213/ANE.0000000000002579
5 Boehnke KF, Litinas E, Clauw DJ. Medical Cannabis Use Is Associated With Decreased Opiate Medication Use in a Retrospective Cross-Sectional Survey of Patients With Chronic Pain. J Pain 2016;17:739–44. doi:10.1016/j.jpain.2016.03.002
6 Boehnke KF, Scott JR, Litinas E, et al. Pills to Pot: Observational Analyses of Cannabis Substitution Among Medical Cannabis Users With Chronic Pain. J Pain 2019;20:830–41. doi:10.1016/j.jpain.2019.01.010
7 Boehnke KF, Scott JR, Litinas E, et al. High-Frequency Medical Cannabis Use Is Associated With Worse Pain Among Individuals With Chronic Pain. J Pain 2019;17:1135–6. doi:10.1016/j.jpain.2019.09.006
8 Campbell G, Hall WD, Peacock A, et al. Effect of cannabis use in people with chronic non-cancer pain prescribed opioids: findings from a 4-year prospective cohort study. Lancet Public Heal 2018;3:e341–50. doi:10.1016/S2468-2667(18)30110-5