Why NICE is wrong?

Tiejun Tang

On 24 March, the National Institute for Health and Clinical Excellence (NICE) released a draft of its updated guideline. Acupuncture, recommended in the previous version was no longer being recommended for the treatment of non-specific low back pain and sciatica.

Acupuncturist across the UK have expressed serious concerns regarding the correctness of the findings expressed in this revised guideline, and formal responses have been made by primary stakeholders such as ATCM and BAcC. Research evidence, clinical case records and statistical analysis have all been collated and provided to NICE, electronically, in hard copy, and verbally at the NICE Public Board Meeting on 18^th May, by representatives of the above professional bodies

Why NICE is wrong in this case?    

Firstly, measures applied to the assessment of effectiveness of a pain killer are not appropriate for the assessment of a therapy such as acupuncture.

Pain killer is a fixed production, each tablet has the exactly same chemical component, the same doses, of course it will produce the same effect on human whom suffer from the same disease. Acupuncture is not a production, it is a therapy. Although all acupuncture treatment looks similar, practitioners just simply insert needles into skin, but the acupoints selection is different, the depth, angles and manipulation are much different. Acupuncture is a therapy which depends on the technique and knowledge of individual practitioner. The effects of acupuncture are varied. How can we evaluate acupuncture effect just based on few clinical trial reports?

The comparison of a pharmaceutical intervention against a placebo can give a representative and absolute analysis of the effectiveness of that pharmaceutical, but the efficacy of a therapy cannot be confirmed in such a manner, as the therapeutic results are entirely dependent on the case by case treatment administered by the practitioner. The so called placebo or ‘sham’ treatment is effectively an attempt at consistent malpractice on the part of the practitioner. Appendectomy is recommended by NICE for acute appendicitis treatment, but if the operator is a physician or an acupuncturist nobody will recommend this operation.

Secondly, side effects should be taken in to account when assessing the effectiveness of a treatment.

Pain killers usually have very good effect after taken or injection. But its side effect shouldn’t be ignored. In clinical we often found some pain killers released joint pain or headache but it cause stomachache or liver function damage. From paracetamol to tramadol and morphine, their side effect is proportional to their function. Better effect always along with stronger side effects. Long term use pain killer will lead another problem – addiction. Acupuncture can reduce the doses of pain killers and even can replace the pain killer that is why it was widely accepted by patients all over the world. If NICE stop recommend acupuncture for treat low back pain, more patient will suffer from the side effects of pain killers.

Thirdly, there is the cost dimension.

The cost of direct health care for back pain in the UK in 1998 was estimated to be £1,632 million^[1]. The management of chronic back pain amounting to 4.6 million appointments per year or 793 full time GPs at a cost of £69 million^[2]. This is on the basis of the current shared workload between General Practitioners and Acupuncturists. If NICE stop recommend acupuncture in low back pain treatment this number will be definitely higher in the future.

NCEI had made a lot right direction to the public health in the past 17 years, but this time I have to say they are completely wrong. They should reconsider their conclusions in respect of acupuncture for low back pain and sciatica. Otherwise it will mislead public to the wrong direction of their treatment.

Reference

1.      Maniadakis, N. The economic burden of back pain in the UK. Pain. 2000; 84(1): 95–103.

2.      Belsey, J. Primary care workload in the management of chronic pain. A retrospective cohort study using a GP database to identify resource implications for UK primary care. Journal of Medical Economics.2002; 5, 39-50.