Acupuncture for Pain Management, Nausea and Vomiting, and Opioid Dependence

Section: Surgery
Effective Date: January 01, 2020
Revised Date: November 14, 2019

Description

Acupuncture is a traditional form of Chinese medical treatment that has been practiced for over 2000 years. It involves piercing the skin with needles at specific body sites. The placement of needles into the skin is dictated by the location of meridians. These meridians, or channels, are thought to mark patterns of energy, called Qi (Chi), that flow through the human body. According to traditional Chinese philosophy, illness occurs when the energy flow is blocked or unbalanced, and acupuncture is a way to influence chi and restore balance. Another tenet of this philosophy is that all disorders are associated with specific points on the body, on or below the skin surface.

Several physiologic explanations of acupuncture's mechanism of action have been proposed, including an analgesic effect from the release of endorphins or hormones (e.g., cortisol, Oxytocin), a bio-mechanical effect, and/or an electromagnetic effect.

There are 361 classical acupuncture points located along 14 meridians, and different points are stimulated depending on the condition treated. In addition to traditional Chinese acupuncture, there are a number of modern styles of acupuncture, including Korean and Japanese acupuncture. Modern acupuncture techniques can involve stimulation of additional non-meridian acupuncture points. Acupuncture is sometimes used along with manual pressure, heat (moxibustion), or electrical stimulation (electroacupuncture). Acupuncture treatment can vary by style and by practitioner and is personalized to the patient. Thus, patients with the same condition may receive stimulation of different acupuncture points.

The scientific study of acupuncture is challenging due to the multi-factorial nature of the intervention, variability in practice, and individualization of treatment. There has been much discussion in the literature on the ideal control condition for studying acupuncture. Ideally, the control condition should be able to help distinguish between specific effects of the treatment and nonspecific placebo effects related to factors such as patient expectations and beliefs and the patient-provider therapeutic relationships. A complicating factor in the selection of a control treatment is that it is not clear whether all 4 components (ie, the acupuncture needles, the target location defined by traditional Chinese medicine, the depth of insertion, and the stimulation of the inserted needle) are necessary for efficacy. Sham acupuncture interventions vary; they can involve, e.g., superficial insertion of needles or insertion of needles at the "wrong" points. A consensus recommendation on clinical trials of acupuncture, published by White et al (2002), recommend distinguishing between a penetrating and a nonpenetrating sham control.

Acupuncture has been used to treat a large variety of conditions. This review addresses acupuncture for treating chronic pain, to ameliorate nausea and vomiting symptoms, and to alleviate withdrawal symptoms of opioid users.

Regulatory Status

The U.S. Food and Drug Administration has cleared acupuncture needles for marketing but does not regulate the practice of acupuncture.

Criteria

Acupuncture may be considered medically necessary for treatment of episodic migrainesand/ortension-type headaches.

Acupuncture is considered investigational for the treatment of other pain-related conditions including but not limited to:

  • Low back pain
  • Shoulder pain
  • Lateral elbow pain
  • Carpal tunnel syndrome
  • Cancer pain in adults
  • Chronic pain in patients with spinal cord injury
  • Pain in endometriosis
  • Pain in rheumatoid arthritis

Acupuncture is considered investigational for the prevention or treatment of nausea and/or vomiting.

Acupuncture is considered investigational for opioid reduction or cessation in opiate users.

Procedure Codes

97810 97811 97813 97814

Diagnosis Codes

G43.001 G43.009 G43.011 G43.019 G43.101 G43.109 G43.111
G43.119 G43.B0 G43.B1 G43.C0 G43.C1 G43.D0 G43.D1
G43.801 G43.809 G43.811 G43.819 G43.821 G43.829 G43.839
G43.901 G43.909 G43.911 G43.919 G44.201 G44.209 G44.211
G44.219 G44.221 G44.229

Professional Statements and Societal Positions Guidelines

Practice Guidelines and Position Statements

American College of Rheumatology

The 2012 guidelines from the American College of Rheumatology on the treatment of osteoarthritis (OA) with acupuncture recommended the following:

"Treatment with traditional Chinese acupuncture or instruction in the use of transcutaneous electrical stimulation are conditionally recommended only when the patient with knee OA has chronic moderate to severe pain and is a candidate for total knee arthroplasty but either is unwilling to undergo the procedure, has comorbid medical conditions, or is taking concomitant medications that lead to a relative or absolute contraindication to surgery or a decision by the surgeon not to recommend the procedure…."

National Institute for Health and Care Excellence

In 2012, the National Institute for Health and Care Excellence guidance on the diagnosis and management headaches in those over 12 years of age recommended a course of up to 10 sessions of acupuncture over 5 to 8 weeks for prophylactic treatment of chronic tension-type headaches.

For migraines, the guidance recommended a course of up to 10 sessions of acupuncture over 5 to 8 weeks for prophylactic treatment if both Topiramate and Propranolol were unsuitable or ineffective.

The 2016 Institute guidance on the assessment and management of low back pain and sciatica in those over 16 years of age recommended not offering acupuncture for low back pain with or without sciatica.

Links

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  1. World Health Organization (WHO). A Proposed Standard International Acupuncture Nomenclature: Report of a WHO Scientific Group. 1991; http://apps.who.int/medicinedocs/en/d/Jh2947e/4.3.html. Accessed October 28, 2018.
  2. White P, Lewith G, Berman B, et al. Reviews of acupuncture for chronic neck pain: pitfalls in conducting systematic reviews. Rheumatology (Oxford). Nov 2002;41(11):1224-1231. PMID 12421994
  3. Food and Drug Administration. Complementary and Alternative Medicine Products and their Regulation by the Food and Drug Administration: Guidance to Industry. 2006;  ttps://www.fda.gov/RegulatoryInformation/Guidances/ucm144657.htm. Accessed October 28, 2018.
  4. Linde K, Allais G, Brinkhaus B, et al. Acupuncture for the prevention of episodic migraine. Cochrane Database Syst Rev. Jun 28 2016(6):CD001218. PMID 27351677
  5. Zhao L, Chen J, Li Y, et al. The long-term effect of acupuncture for migraine prophylaxis: a randomized clinical trial. JAMA Intern Med. Apr 01 2017;177(4):508-515. PMID 28241154
  6. Linde K, Allais G, Brinkhaus B, et al. Acupuncture for the prevention of tension-type headache. Cochrane Database Syst Rev. Apr 19 2016;4:CD007587. PMID 27092807
  7. Lam M, Galvin R, Curry P. Effectiveness of acupuncture for nonspecific chronic low back pain: a systematic review and meta-analysis. Spine (Phila Pa 1976). Nov 15 2013;38(24):2124-2138. PMID 24026151
  8. Furlan AD, van Tulder MW, Cherkin DC, et al. Acupuncture and dry-needling for low back pain. Cochrane Database Syst Rev. Jan 25 2005(1):CD001351. PMID 15674876
  9. Green S, Buchbinder R, Hetrick S. Acupuncture for shoulder pain. Cochrane Database Syst Rev. Apr 18 2005(2):CD005319. PMID 15846753
  10. Green S, Buchbinder R, Barnsley L, et al. Acupuncture for lateral elbow pain. Cochrane Database Syst Rev. 2002(1):CD003527. PMID 11869671
  11. O'Connor D, Marshall S, Massy-Westropp N. Non-surgical treatment (other than steroid injection) for carpal tunnel syndrome. Cochrane Database Syst Rev. 2003(1):CD003219. PMID 12535461
  12. Paley CA, Johnson MI, Tashani OA, et al. Acupuncture for cancer pain in adults. Cochrane Database Syst Rev. Oct 15 2015(10):CD007753. PMID 26468973
  13. Boldt I, Eriks-Hoogland I, Brinkhof MW, et al. Non-pharmacological interventions for chronic pain in people with spinal cord injury. Cochrane Database Syst Rev. Nov 28 2014(11):CD009177. PMID 25432061
  14. Zhu X, Hamilton KD, McNicol ED. Acupuncture for pain in endometriosis. Cochrane Database Syst Rev. Sep 07 2011(9):CD007864. PMID 21901713
  15. Casimiro L, Barnsley L, Brosseau L, et al. Acupuncture and electroacupuncture for the treatment of rheumatoid arthritis. Cochrane Database Syst Rev. Oct 19 2005(4):CD003788. PMID 16235342
  16. Boelig RC, Barton SJ, Saccone G, et al. Interventions for treating hyperemesis gravidarum. Cochrane Database Syst Rev. May 11 2016(5):CD010607. PMID 27168518
  17. Matthews A, Haas DM, O'Mathuna DP, et al. Interventions for nausea and vomiting in early pregnancy. Cochrane Database Syst Rev. Sep 08 2015(9):CD007575. PMID 26348534
  18. Ezzo J, Streitberger K, Schneider A. Cochrane systematic reviews examine P6 acupuncture-point stimulation for nausea and vomiting. J Altern Complement Med. Jun 2006;12(5):489-495. PMID 16813514
  19. Ezzo J, Richardson MA, Vickers A, et al. WITHDRAWN: Acupuncture-point stimulation for chemotherapy-induced nausea or vomiting. Cochrane Database Syst Rev. Nov 21 2014(11):CD002285. PMID 25412832
  20. Lee A, Chan SK, Fan LT. Stimulation of the wrist acupuncture point PC6 for preventing postoperative nausea and vomiting. Cochrane Database Syst Rev. Nov 02 2015(11):CD003281. PMID 26522652
  21. Windmill J, Fisher E, Eccleston C, et al. Interventions for the reduction of prescribed opioid use in chronic non-cancer pain. Cochrane Database Syst Rev. Sep 01 2013(9):CD010323. PMID 23996347
  22. Lin JG, Chan YY, Chen YH. Acupuncture for the treatment of opiate addiction. Evid Based Complement Alternat Med. 2012;2012:739045. PMID 22474521
  23. Hochberg MC, Altman RD, April KT, et al. American College of Rheumatology 2012 recommendations for the use of nonpharmacologic and pharmacologic therapies in osteoarthritis of the hand, hip, and knee. Arthritis Care Res (Hoboken). Apr 2012;64(4):465-474. PMID 22563589
  24. National Institute for Health and Care Excellence (NICE). Headaches in over 12s: diagnosis and management [CG150]. 2012; https://www.nice.org.uk/guidance/cg150/resources/headaches-in-over-12s-diagnosis-and-management-pdf-35109624582853. Accessed October 28, 2018.
  25. National Institure for Health and Care Excellence (NICE). Low back pain and sciatica in over 16s: assessment and management [NG59]. 2016; https://www.nice.org.uk/guidance/ng59/resources/low-back-pain-and-sciatica-in-over-16s-assessment-and-management-pdf-1837521693637. Accessed October 28, 2018.
  26. Center for Medicare & Medicaid Services (CMS). National Coverage Determination (NCD) for ACUPUNCTURE (30.3). n.d.; https://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=11&ncdver=1&CoverageSelection=National&KeyWord=acupuncture&KeyWordLookUp=Title&KeyWordSearchType=And&clickon=search&bc=gAAAACAAAAAAAA%3d%3d&. Accessed October 28, 2018.
  27. Center for Medicare & Medicaid Services (CMS). Decision Memo for ACUPUNCTURE for Fibromyalgia (CAG-00174N). 2003; https://www.cms.gov/medicare-coverage-database/details/nca-decision-memo.aspx?NCAId=83&CoverageSelection=National&KeyWord=acupuncture&KeyWordLookUp=Title&KeyWordSearchType=And&clickon=search&bc=gAAAACAACAAAAA%3d%3d&. Accessed October 20, 2018.
  28. Center for Medicare & Medicaid Services (CMS). Decision Memo for Acupuncture for Osteoarthritis (CAG-00175N). 2003; https://www.cms.gov/medicare-coverage-database/details/nca-decision-memo.aspx?NCAId=84&CoverageSelection=National&KeyWord=acupuncture&KeyWordLookUp=Title&KeyWordSearchType=And&clickon=search&bc=gAAAACAACAAAAA%3d%3d&. Accessed October 28, 2018.