The safety of acupuncture

Editorials

The safety of acupuncture

Acupuncture is safe in the hands of competent practitioners

Papers pp 485, 486

For many patients attracted to complementary medicine its safety has been one of its principal appeals. Complementary methods,including acupuncture, are seen as less invasive, more natural,and less liable to adverse effects than more orthodox forms oftreatment. Critics of complementary medicine have, however, oftencastigated it as being dangerous, sometimes in the same breathas ridiculing complementary methods for their lack of effectivenessand scientific support. For many years, certainly until the mid-1980s,these debates were little more than exchanges of usually entrenchedand unwavering opinion on either side.¹ Now we begin to havesomeevidence.

The early literature on the safety of acupuncture consisted entirely of case reports. Rampes and James summarised all casereports between 1966 and 1993, finding 395 instances of complications.²Many were minor, such as bruising or fainting, but 216 were serious,including several cases of pneumothorax and injury to the spinalcord. Only one death due to acupuncture was reported, in whicha needle penetrated the pericardium. As the acupuncture was selfadministered, however, this perhaps falls outside the usual definitionof adverse events, straying into the territory of domestic injuryor deliberate self harm. In 1995 a survey in Norway found that12% of doctors and 31% of acupuncturists had encountered adverseeffects of acupuncture in their practice, including pneumothorax,nerve injury, infections, nausea and vomiting, and fainting.³However, there was little indication of the period over whichevents were reported or the frequency with which complicationsoccurred. More recently further cases of potentially life threateningcomplications have been reported.⁴

Important though such case reports and informal surveys are in flagging up problems, they are limited by the absence of denominatorinformation. Assessing the degree of risk requires knowledge ofboth frequency and severity of thehazard.

Complications are rare and transient
Two reports in this week's issue are the firstto systematically examine both the rate and nature of adverseeffects of acupuncture (pp 485, 486). ⁵ ⁶ Both suggest thatthe rate of complications is remarkably low and that most complicationsare transient, lasting two weeks at most. In total the two reportscover over 66 000 treatments given by doctors, physiotherapists,and traditional acupuncturists, with little obvious differencein either the type or rate of complications between the differentgroups.

What limitations do these reports have? Firstly, as with any incident reporting system, the actual incidence of adverse eventsis probably higher than reported. Nevertheless, these studieswere of relatively short duration and it is reasonable to supposethat most adverse events reported by patients would have beenpassed on by the practitioner to the investigators. Anonymousreports were permitted, thus reducing any disincentive to reportingserious events. The surveys are restricted to immediate complicationsof treatment, so longer term deleterious effects on the patient'scondition or interactions with concurrent treatments would probablynot have beenidentified.

The absence of serious adverse events is reassuring, but it is important to note the characteristics of the population surveyed.The participants in these surveys would all have received trainingin acupuncture and be members of professional associations whohave chosen to give a high priority to professional standardsand patient safety. With many of the earlier case reports, fromaround the world, the training and experience of the acupuncturistwas unclear. Rampes and James pointed out that many of the problemsin their case series could easily have been avoided by a competentpractitioner.²

Evidence of benefit is rare too
The conclusion that acupuncture is a verysafe intervention in the hands of a competent practitioner seemsjustified on the evidence available. Certainly the dangers ofmany orthodox procedures are greater, though no easy comparisonscan be made. The considerable risks of hospital treatment arebecoming apparent,⁷ but the nature of the conditions treated,the interventions themselves, and the settings are different.A better comparison might be primary care, but the risks of adverseeffects in this setting are largely unknown. Rates of adversedrug reactions or prescribing errors in primary care have variedfrom 0.5% to 6% at community pharmacies.⁸ While the risks ofacupuncture cannot be discounted, it certainly seems, in skilledhands, one of the safer forms of medicalintervention.

Yet simply comparing treatments on the basis of their associated risks gives a limited perspective. The balance of risk andbenefit is the key for patients and for those regulating or fundinghealth care. As White et al point out, for many conditions thebalance of risk and benefit for acupuncture remains to be determined.⁵Depressingly, the conclusion of many recent systematic reviewshas been similar to the first reviews carried out 15 years ago:conflicting findings and too few studies of too small a size todraw firm conclusions. ¹ ⁹ ¹⁰ Nevertheless, trial methodsin acupuncture have improved substantially in the past decade,and there is some positive evidence emerging for its efficacyin treating headache and nausea and vomiting. ¹¹ ¹²

Most encouragingly, the surveys reported today represent a serious and systematic attempt by acupuncture practitioners toaddress the issue of patient safety, paralleling the emergenceof wider patient safety initiatives in many countries. We havemoved a long way from the sterile and hostile debates betweencritics and advocates of complementary medicine and can look forwardto a time when any proposed treatment is evaluated on the basisof its efficacy, risks, likely mechanisms, acceptability, andcost effectiveness regardless of itsprovenance.

Charles Vincent, professor of psychology.

Clinical Risk Unit, Department of Psychology, University College London, London WC1E 6BT (c.vincent@ucl.ac.uk)

1.	Vincent CA, Furnham A. Complementary medicine. A research perspective. Chichester: Wiley, 1997.
2.	Rampes H, James R. Complications of acupuncture. Acup Med 1995; 13: 26-33.
3.	Norheim AJ, Fonnebo V. Adverse effects of acupuncture. Lancet 1995; 345: 1576[Medline].
4.	Ernst E, White A. Acupuncture: safety first. BMJ 1997; 314: 1362[Full Text].
5.	White A, Hayhoe S, Hart A, Ernst E. Adverse events following acupuncture: prospective survey of 32 000 consultations with doctors and physiotherapists. BMJ 2001; 323: 485-486.
6.	MacPherson H, Thomas K, Walters S, Fitter M. The York acupuncture safety study: prospective survey of 34 000 treatments by traditional acupuncturists. BMJ 2001; 323: 486-487.
7.	Vincent CA. Risk, safety and the dark side of quality. BMJ 1997; 314: 1775-1776[Full Text].
8.	Rogers S. Risk management in general practice. In: Vincent CA, ed. Clinical risk management: enhancing patient safety. London: BMJ Books, 2001:241-260.
9.	Richardson PH, Vincent CA. Acupuncture for the treatment of pain: a review of evaluative research. Pain 1986; 24: 15-40[Medline].
10.	White AR, Ernst E. A systematic review of randomised controlled trials of acupuncture for neck pain. Rheumatology 1999; 38: 143-147[Medline].
11.	Melchart D, Linde K, Fischer P, White A, Allais G, Vickers A, et al. Acupuncture for recurrent headaches: systematic review of randomised controlled trials. Cephalgia 1999; 19: 779-786[Medline].
12.	Lee A, Done ML. The use of nonpharmacologic techniques to present postoperative nausea and vomiting: a meta-analysis. Anesthes Analges 1999; 88: 1362-1369[Abstract/Full Text].

© BMJ 2001

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