Tuesday, 12 April 2016 11:30

Double standards in evidence: NICE no longer wants to recommend acupuncture for back pain

In October 2013 I went to a stakeholders workshop to hear about, and discuss, NICE’s plan for an updated guideline on low back pain. The 2009 recommendation of acupuncture has become a key part of BAcC marketing and may have knock-on effects for all of us through increased acceptability in orthodox medical circles. However, the acupuncture recommendation has never gained much of a foothold when it comes to funding primary care services, leaving NICE with egg on its face. This was one of the stated reasons for the guideline update. One solution would be to persuade the NHS to comply with the recommendation; the easier and cheaper option would be simply to uncouple acupuncture.

Back to the scoping workshop, which was populated by an impressive variety of stakeholder representatives: different sorts of doctors, nurses and physiotherapists, pharmacists and drug companies, patient groups, and a smattering of CAM people – acupuncture, osteopathy, chiropractic and others. We hear the plan; we talk in groups; we reconvene and report. The orthodox medics are quite simpatico about acupuncture but it doesn’t really enter their world: largely they chew over NHS tactics. One notable non-simpatico person was the chair for the new guideline development group (GDG), who had the air of a man who sees acupuncture as a diversion from the serious business of the NHS. We have no say in his appointment but stakeholders are asked to nominate for the other places in the GDG. There’s no acupuncturist slot within the group, just an expert advisor position, which allows no general involvement and no voting rights. We agitated to change this, but to no avail, and this was probably another nail in the coffin.

The GDG was up and running 2-3 months later and very soon there was gossip that the prospects for acupuncture didn’t look good. The UK acupuncture associations convened, consulted, lobbied and protested; BAcC attended NICE Board meetings and targeted its executives and committee members, but the word on the street continued to indicate that the GDG had gone to the dark side. Someone dug up information about the chair and another group member, speeches/writing that appeared to confirm their anti-acupuncture stance. This was used to challenge NICE as to their impartiality and the fairness of the whole process.

On 25 March 2016 they released the draft guideline: acupuncture is no longer recommended. This is open for consultation until 5 May and the final version will be published in September. Exercise and anti-inflammatories will be left as the core interventions, with manipulation and psychological therapies allowed as adjuncts to these, and radio wave denervation for facet joint pain. To be fair, not only acupuncture has suffered. Orthotics and electrotherapies are also for the chop, along with surgery and injections (except for sciatica) and, for the most part, all other drugs.

How could this have happened: acupuncture good in 2009, bad in 2016? There is some more data, more trials, but the results are pretty much the same – better if anything, due to the larger numbers – so this is a matter of changing interpretations. In 2009 they took a pragmatic approach: ‘we’re not sure about the whole sham/placebo thing but acupuncture is better than usual care, and it’s cost-effective, so let’s give it the benefit of the doubt’. But now attitudes have hardened: ‘we don’t find acupuncture to be clinically superior to sham and so we don’t believe it has an effect other than as a placebo; hence we won’t even consider its cost-effectiveness’. Now, NICE’s favoured treatment is exercise, but sham exercise trials are thin on the ground. Two relevant studies were found but NICE has magically transformed their negative results into positive ones (http://blogs.bmj.com/aim/2016/03/31/nice-exercise-not-acupuncture/). Nobody would want to deny exercise (which includes yoga and tai qi) a place at the table but its supporting evidence is no better than that for acupuncture. The difference is in the extra barrier that NICE erects for acupuncture: the need to show clinical superiority over sham, a wildly inappropriate and practically impossible demand. Not exactly a level playing field. The sense is of acupuncture as an alien therapy requiring more stringent quarantine rules.

So there’s a lot to object to and argue with in this, just as there was two years ago with OA. NICE has used much the same decision making logic as then, and they quote OA as a precedent. The worry is that this becomes the standard approach for future guidelines.

What can we do?

The OA example does not auger well. Outcry from doctors may have pushed NICE into easing up on the drugs allowed – and this may happen again with back pain – but acupuncture has nothing like the same clout. We have been preparing a BAcC response since the draft report emerged but there is also a coordinated project drawing together various experts to produce a comprehensive scientific rebuttal. As well as the exercise data errors mentioned above others are being discovered for acupuncture, so the whole massive document needs going through with a fine tooth-comb.  This will result in a stronger reply than for OA. Other interested stakeholders will be responding to NICE along similar lines. As well as these direct comments there needs to be wide-ranging action to inform and protest:

It may well be that nothing we can do or say will get them to reverse this decision; nevertheless, to say nothing and take it on the chin is not an option. The issues raised in this guideline are not new ones but they are still poorly understood. It’s not just NICE we are reaching out to but all guideline groups, the medical authorities, the DoH, other medical professionals, the media and the public. This is part of the ongoing struggle for scientific credibility and official recognition that may take many years.