A large Australian study has deemed acupuncture equivalent and non-inferior to pharmacotherapy in providing analgesia for back and ankle pain
However both options were considered inadequate for pain relief within one hour of presentation.
While pain is the most common reason for emergency department (ED) presentations in Australia, it is “often inadequately managed”, according to research led by RMIT University and published in the Medical Journal of Australia.
The researchers set out to determine whether acupuncture could provide effective pain relief in patients with lower back pain, migraine or ankle sprain.
Of 1964 patients presenting to four Melbourne emergency departments between January 2010 and December 2011, 528 patients who a verbal pain score of at least 4 (out of 10) were recruited.
And of these, 270 (51%) had acute low back pain, 92 (17%) had migraine and 166 (31%) had ankle sprain.
Participants were evenly randomised into three groups: acupuncture alone; acupuncture plus pharmacotherapy; and pharmacotherapy alone.
Acupuncture was provided by either a registered Chinese medicine practitioner or an ED physician with medical acupuncture qualifications.
Pharmacotherapy was administered according to standardised protocol, with first-line options including diazepam (5mg), Hartmann’s solution, Metoclopramide or proclorperazine, paractamol, paracetamol with codeine, tramadol, dextropropoxyphene and paracetamol; ibuprofen, diclofenac and indomethacin; as well as second-line therapy options including morphine and chlorpromazine.
Combined treatment included acupuncture administered 15 minutes either before or after pharmacotherapy.
All ankle injury patients received rest, ice, compression and elevation, and rescue therapy (including parenteral opiates) was available to patients with inadequate pain relief after one hour.
Equivalence and non-inferiority of treatment groups was found overall, and for the low back pain and ankle sprain groups in both intention-to-treat and per protocol analyses.
About 15.6% of patients had clinically relevant pain relief, and 36.9% had statistically relevant pain relief, with no between-group differences.
After one hour, 47% of the acupuncture only group, 49% of the combined group, and 57% of the pharmacotherapy only group stated they would definitely repeat their treatment.
After 48 hours, the number of patients willing to repeat acupuncture had increased (61%), compared with 57% of the combined therapy group, and 52% of the pharmacotherapy only group.
“This study was the largest randomised controlled trial of acupuncture in an ED,” say the researchers.
“We found that acupuncture, alone or in conjunction with pharmacotherapy, provides analgesia comparable with that achieved by pharmacotherapy for patients presenting to the ED with low back pain and ankle sprain, but not for those with migraine.
“Although all three treatments were similarly ineffective at reducing pain at [the one-hour mark], most patients found their treatment acceptable at [the 48-hour mark), about 80% of each group stating they would probably or definitely repeat their treatment.”
Notably, the acupuncture only group received significantly more rescue medication therapy than the groups that received pharmacotherapy (at one hour: P = 0.016; after one hour: P = 0.008).
“This may indicate that acupuncture was ineffective and patients sought alternative analgesia, or that they were more likely to accept pharmacotherapy because they felt they had missed out on standard care, whereas patients who had already received oral opiates were reluctant to accept parenteral opiates,” suggest the authors.
“Patients treated with acupuncture who received rescue medication were classified as having received pharmacotherapy in the per protocol analysis, in which the equivalence and non-inferiority of groups were maintained, but we cannot discount that this may partly reflect the potentially self-limiting nature of the treated conditions.”
Altogether, none of the therapeutic strategies used provided optimal analgesia within one hour of presentation.
The researchers say there is a clear demand for more effective analgesia in the ED, and suggest acupuncture as a safe alternative to pharmacotherapy, particularly given concerns surrounding the use of opioids and the potential for addiction.
See the study here.