Why isn't acupuncture offered on the NHS more frequently?
I am not suggesting acupuncture is a miracle waiting to save the NHS. It is almost certainly not going to cure cancer (although the Royal Surrey hospital have a full-time acupuncturist for cancer patients and their support). Or cardiovascular disease. The NHS and biomedicine are amazing.
But, there are many things that acupuncture is VERY good at and I have been puzzling away on why my local GPs and Practice Managers are not replying to my emails of a conversation (I suspect they are very busy).
So, I have decided to come up with a business case. Which I am also sharing with you.
We know acupuncture is excellent for chronic pain. The National Institute of Care and Excellence recommends acupuncture for headaches. It also recommends acupuncture for chronic pain.
On the NHS website acupuncture is listed as a treatment for headaches and migraines.
Acupuncture could help ease the burden of waitlists that stretch for miles (currently in North and East Hertfordshire there is an average wait time of 72 weeks for pain management).
Remove or reduce the dependency on medication
A referral from a GP on the NHS may allow for costs to be carried not by the patient but by the NHS.
So, why can we not create a collaborative approach which puts the patient's needs at the forefront and offer acupuncture more frequently, or even as an option? I would love to work with my local GPs and NHS providers to create a pathway for their patients to access acupuncture.
Let us test and learn using the evidence and the costs as our guide.
It isn't a lack of evidence (see below)
Or that acupuncture is not safe (when practised by a degree-level acupuncturist)
Today's blog is going to examine the costs associated with chronic pain in the UK and the safety and efficacy of current steps that are taken by GPs to manage chronic pain. I will then look at the evidence for acupuncture for pain relief, safety records and associated costs.
I hope you enjoy today's blog and please do not ever hesitate to message me with any questions.
Andrea
The problem with chronic pain
I did a virtual presentation in March 2022 about chronic pain (which you can access here). In that presentation, we discussed that pain is hardly ever just about the pain. Pain has an impact on our quality of life, our work life and our home life.
Pain affects our mood, our sleep and also our immediate friends, family and work colleagues.
Pain affects
our physical activity and can cause disability
the ability to walk, do domestic chores, participate in social activities, and have an independent lifestyle
our mental health bringing on or exacerbating symptoms of anxiety or depression
Sleep disturbances are commonly experienced and may impair cognitive ability, in turn affecting everyday activities in the workplace and at home
not being able to go to work
leisure activities and social contacts preventing you from attending social or family events and/or less contact with family
In 2018 it was estimated that 8 million people in the UK lived with chronic pain
However, there is very little consensus around this number.
The British Pain Society in 2022 estimates this to now be 10 million people. That is around 15% of the population or 3 in 20 people.
However, a 2016 study, estimated this to be 28 million people.
So we do not have a good way of reporting the numbers of people experiencing chronic pain. Why?
What is chronic pain?
Chronic pain is any pain lasting longer than 3 months. So this could be:
musculoskeletal
menstruation
headaches/migraines
osteoarthritis
pain associated with treatment e.g. cancer treatment
auto-immune conditions such as lupus
fibromyalgia
This list is not exhaustive, so perhaps it isn't unreasonable that we cannot grasp the scale of pain. It is also feasible that people have not seen their doctor with pain, preferring self-management.
This definition below is taken from the Derbyshire CCG
Primary chronic pain is considered to be pain without an underlying cause. Examples might be:
fibromyalgia
chronic primary headache
chronic primary musculoskeletal pain
chronic primary visceral pain
Secondary chronic pain is pain that has an identifiable underlying cause. Examples are:
endometriosis
headache
IBS
low back pain and sciatica
osteoarthritis
rheumatoid arthritis
Going to the GP with chronic pain
Currently, when going to your local General Practitioner (GP), you will fall under a CCG (these are meant to be changing in April 2022).
Clinical commissioning groups (CCGs) assess the needs of their local area e.g. the number of people, age, deprivation and then 'buy' services from hospitals, GP surgeries, mental health groups, charities etc based on this. You can find a list of CCGs here.
They aim to get
"the best possible health outcomes for their local population"
and CCGs are predominantly made up of GPs.
To find out more about how the NHS is structured and how decisions/funding is made, here is a brilliant resource by the King's Fund.
This means your particular GP, depending on which CCG they fall under, may have a very different remit to another town over (in a different CCG).
If, for example, you go to your GP in Derbyshire for chronic pain the first-line options are:
Offer supervised group exercise programme
Consider psychological therapy (acceptance and commitment therapy (ACT) or cognitive behavioural therapy (CBT)
Consider a single course of acupuncture or dry needling, within a traditional Chinese or Western acupuncture system, only if it is delivered as described by NICE in a community setting. Note acupuncture for pain management is not currently commissioned in Derbyshire. See position statement.
The first line of medication that will be offered to you is an anti-depressant.
If you are going to your GP, in Derbyshire, with lower back pain or sciatica then you will be offered in the first instance:
Self-management advice e.g. weight loss, keeping as active as possible
group exercise programme
manual therapy and/or psychological therapies (cognitive behavioural approach)
Pharmacological treatments offered for lower back pain or sciatica would be:
NSAIDs such as Ibuprofen or naproxen
Lansoprazole or omeprazole
Do NOT routinely offer opioids for managing acute low back pain. Consider weak opioid (first line- codeine) with or without paracetamol for managing acute low back pain, only if an NSAID is contraindicated, not tolerated or has been ineffective.
NICE does NOT recommend gabapentinoids or antiepileptics but reserves the option to use gabapentinoids and some antiepiliptics e.g. carbamazepine, oxcarbazepine for a small number of selected individuals after considering all other options.
So, unfortunately, acupuncture whilst being on the list, for chronic pain, is not offered in Derbyshire.
What about the safety of those recommendations from your GP?
Your GP is a safe and experienced professional. They follow many guidelines to make decisions based on your condition and NICE guidelines.
Any medication you are prescribed has side effects. Even paracetamol, which despite being a familiar over the counter medication they are now asking for caution when taking if pregnant.
Opioids
Opioid prescriptions between 1998 and 2016 almost doubled in the UK and you may be aware of the opioid crisis with the US reporting increases in deaths from opioid misuse.
So, what is an opioid? It is a prescription medicine to help with moderate to severe pain.
And again in the UK, we are seeing more people with long-standing illnesses or disabilities misusing prescription medication
Among those with a long-standing illness, 8.5 per cent had misused prescription-only painkillers in the last year (compared with 4.8% without an illness) and 11.9 per cent had taken an illicit drug in the last year (compared with 8.1% without an illness).
What other medication might be offered?
NSAIDS
NSAIDs or Non-steroidal anti-inflammatory drugs are medicines that are used to relieve pain and or reduce inflammation.
However, in the British Medical Journal in 2017, they reported that
"All NSAIDs, including naproxen, were found to be associated with an increased risk of acute myocardial infarction"
and they found that short term use (8-30 days) at a high daily dose (celecoxib >200 mg, diclofenac >100 mg, ibuprofen >1200 mg, and naproxen >750 mg) is associated with the greatest harms, without obvious further increases in risk beyond the first 30 days.
SSRIs
Selective serotonin reuptake inhibitors (SSRIs) are a widely used type of antidepressant and are used in chronic pain to help with the quality of life.
Amitriptyline is the first medication mentioned by the Derbyshire prescribing committee and this photo below is a list of side effects taken from the British National Formulary.
I am not saying that medication isn't amazing. It saves lives. I am just trying to point out that nothing is without risk when taking medication.
One thing to note however about pain relief and women. In a 2006 study, they found
"women were still 13% to 25% less likely than men to receive opioid analgesia. There was no gender difference in the receipt of nonopioid analgesia. Women waited longer to receive their analgesia (median time 65 minutes vs. 49 minutes, difference 16 minutes, 95% CI = 3.5 to 33 minutes)"
What are the costs of chronic pain?
The cost of chronic pain is virtually impossible to understand.
Pain falls under BNF chapters 4 and 10 which make the picture very hard to navigate when looking at the 'cost' of pain in the NHS and medication. We would need to understand
GP costs
Staff costs
Medication costs (prescription and over the counter)
Loss of work costs
Quality of life costs
We do not even know the true scale of how many people suffer from chronic pain
The table below is taken from the NHS Business Services Authority from 2020/2021. The cost of items for Chapter 4 is £1,710,000,000. That is one billion seven hundred ten million. These medications are not all just pain relief, but this category covers pain and mental health conditions.
BNF Chapter 4 = CNS which includes pain and mental health
BNF Chapter 10 = Musculoskeletal
In a 2009 publication for the British Pain Society they found:
The indirect cost of back pain in the UK was estimated to be between £5 billion and £10.7 billion in 1998, depending on the approach employed
Musculoskeletal complaints, predominantly mild to moderate in severity, and often with no clear or consistent underlying pathology, account for around 20% of benefit recipients in the UK and therefore account for a significant proportion of incapacity for work. Given that the annual economic costs associated with sickness absence and worklessness amount to over £100 billion, the impact of pain and associated conditions remains a significant contributory factor.
In the UK back pain was estimated to cost the NHS £1 billion per annum
Primary care management of patients with chronic pain accounted for 4.6 million appointments per year in the UK, equivalent to 793 whole time general practitioners (GPs), at a total cost of around £69 million, with poor efficacy the trigger for almost as many consultations as poor tolerability. In addition to ineffective treatments, there are issues relating to unnecessary referrals, treatment, and diagnostic tests, and these are of particular concern as they are potentially avoidable
In the UK, based on a prevalence of chronic pain of 10%, it has been estimated that there are 2,150 million chronic pain days per year
Found on the Health Education and Improvement Wales website they said that Chronic non-malignant pain (CNMP) accounted for:
15-22% of all GP consultations
10% of all prescribed medications are for chronic pain
1% are seen in chronic pain clinics, the rest are managed in primary care (Belsey et al 2002)
2.5 million people have back pain every day of the year and results in a total cost of £12.3 billion (22% of UK healthcare expenditure)
back problems are the leading cause of disability with nearly 119 million days a year lost: one in eight unemployed people give back pain as the reason they are not working
The estimated cost of back pain to the NHS is £481 million a year (min-max range £356 - 649 million), with non-NHS costs (such as private consultations and prescriptions) being an additional £197 million
In the HSJ (Health Service Journal), looking specifically at osteoarthritis they found:
The total annual NHS spend related to arthritis and musculoskeletal conditions in England is roughly £5billion
One-third of over 45s in the UK have sought treatment for OA, totalling 8.75 million people
Finally, in this really interesting report from the Chief Medical Officer in 2008 they found:
7.8 million people live with chronic pain
£3.8 billion costs of adolescent pain
£584 million spent on prescriptions for pain
1 million women suffer from chronic pelvic pain
1.6 million adults per year suffer from chronic back pain
49% of patients with chronic pain experience depression
25% of sufferers lose their jobs
16% of sufferers feel their chronic pain is so bad that they sometimes want to die
1 pain specialist for 32,000 people in pain
They also looked at the percentage of pain medication prescriptions for pain in the UK and compared this to the European average.
In the UK, we were more likely to be taking paracetamol, weak opioids and strong opioids in comparison to our European neighbours.
As you can see it is almost impossible to grasp the numbers and even the true scale of chronic pain and the costs.
But what is clear, is that chronic pain is a BIG problem.
Acupuncture for pain relief: the evidence
I have talked extensively about the evidence of acupuncture for pain relief here.
Acupuncture repeatedly has been shown to be beneficial in the treatment of chronic pain.
I am not saying it is a miracle but I believe it is worth offering patients the choice. Not taking the choice away.
In a study in 2018 of 20,827 patients, they found that
"Effects of acupuncture appear to persist over at least a 12 month period".
It was also found that 50% of those who received acupuncture experienced significant improvement in comparison to 30% for other treatments (medication, physiotherapy, exercise).
So, acupuncture is effective. But is acupuncture safe?
The safety of acupuncture
This is a viable and excellent question. We know that medication can have side effects. So, how safe is acupuncture?
If you are receiving treatment from a qualified, degree-level (minimum 3 years of training), acupuncturist then the risk of injury is low. We are taught safe-needling techniques. We use single-use sterile needles which are checked for integrity. We know red flags and contraindications of treatment.
Mistakes happen. But it is thankfully rare, in acupuncture.
In a 2006 German study, involving 454,920 patients and over 4 million treatments 7.9% of patients reported minor adverse effects while only 0.003% (13 patients) experienced severe adverse events. Minor adverse events included needling pain, haematoma, and bleeding, while serious adverse events included pneumothorax, acute hyper- or hypotensive event, erysipelas, asthma attack, and aggravation of suicidal thoughts.
Does it make sense for GPs to refer chronic pain patients for acupuncture?
Acupuncture is not a miracle. It is a medicine and therefore is fallible. But the evidence is very good.
It also isn't a cheap option. The investment of 10 acupuncture appointments, with me, is £600.
Even, if I take the British Pain Society number of people experiencing chronic pain (10,000,000) that would be £6 billion spent on acupuncture.
But what if acupuncture could help with chronic pain, but also other signs and symptoms?
Insomnia?
IBS?
Anxiety?
Depression?
The benefits might be:
GPs can spend more time on other cases (we know 4.6 million appointments per year in the UK, equivalent to 793 whole time general practitioners (GPs), are used for chronic pain)
A smaller spend on medication (we know approximately £584 million spent on prescriptions for pain)
People being able to return to work (we know sickness absence and worklessness amount to over £100 billion, of which 20% comes from pain = £200,000,000)
BUT most importantly a person's quality of life might be resumed (we know poor efficacy is the trigger for almost as many consultations as poor tolerability. In addition to ineffective treatments, there are issues relating to unnecessary referrals, treatment, and diagnostic tests, and these are of particular concern as they are potentially avoidable