Why recommend acupuncture for low back pain but not for osteoarthritis? A commentary on recent NICE guidelines

I attended a dinner in November 2005 with Sir Michael Rawlins (chairman of the National Institute for Health and Clinical Excellence (NICE)) organised by the King’s Fund to explore some of the issues around the assessment of complementary interventions in the NHS. It was a valuable opportunity to gain an insight into policy making processes and principles, and I specifically remember Sir Michael’s mantra: “Does it work? Is it safe? How much does it cost?” I realised that “Does it work?” referred to specific efficacy confirmed in systematic review of randomised controlled trials (RCTs), rather than pragmatic data on effectiveness in clinical practice. He indicated that there was a growing quantity of suitable evidence (systematic reviews) in the complementary medicine field, and when referring specifically to acupuncture I’m sure he said “We will probably buy acupuncture for back pain, but definitely not for migraine”. At this point I spluttered on my glass of water, and was subsequently invited to comment. I briefly described the issues surrounding sham acupuncture,1 “missing the point”2 and the extraordinary effectiveness of these procedures in the prophylaxis of migraine.3 Sir Michael’s response was simply to comment: “That is your (viz the acupuncture profession’s) problem!”

Around the same time I had a detailed discussion of the research issues of acupuncture for headaches with one of the leading academics in field of migraine. He took a similar approach to the chairman of NICE, in that he would not consider the data on effectiveness or cost effectiveness until the question over specific efficacy (“Does it work?”) was answered satisfactorily.

These interactions with leading academics who had (and still …