The Regulation of the Practice of Acupuncture by Physicians in the United States

Assessing the role and impact of research in clinical practice among acupuncturists in western countries: a multinational cross-sectional survey

Background

Evidence-informed practice is crucial to perform safe and efficient health interventions. In recent years, the evidence base of acupuncture continuously increased leading to the integration of acupuncture into clinical guidelines by various leading medical associations worldwide. At the same time, recent studies showed that licensed acupuncturists are rarely utilizing scientific research to inform their practice.

Methods

This descriptive study using an online survey assessed the role of evidence-informed practice of acupuncturists in Austria, Germany, the United States of America, Australia, and New Zealand and aimed to determine critical factors relevant for promoting research literacy including demographical data, data about the clinical practice patterns, and the role and value of different information sources of traditional, complementary and integrative medicine (TCIM) practitioners.

Results

In total, 404 acupuncturists completed the online survey that included questions about demographic characteristics, the role and value of research in clinical practice, and details about the amount and type of continuing professional education. Univariate and multivariate analysis was used to determine significant predictors of the outcome variable "importance of research in clinical practice" (numerical rating scale, 0 to 100). The results showed that the majority of acupuncturists use certified courses as primary source of continuing professional education and value experts' opinions as the most reliable source of information. Multivariate analysis showed that the importance of research is dependent on the interest in research, an interdisciplinary learning environment, and positive experiences with research including if an acupuncture study ever changed the clinical practice of practitioners.

Conclusion

Future educational programs should therefore focus on an interactive format aiming to promote skills to critically assess the value and practical use of research studies to improve the general practice of acupuncture.

A scoping review of mechanisms of auricular acupuncture for treatment of pain

OBJECTIVES

Auricular acupuncture (AA) is becoming increasingly common in primary care clinics, emergency departments and peri-operatively for pain relief. Over the last decade, since the last comprehensive reviews were published, the literature has expanded. In this scoping review, we seek to document the efficacy of AA in treating both acute and chronic pain, describe the mechanism of action of AA in treating pain, and discuss how AA has been integrated into Western medicine to date.

METHODS

The authors performed a MEDLINE search inclusive of articles from 1966 to June 2023 including articles written in English identifying literature. We included human studies when more than 3 patients were included. Three hundred and fourteen unique articles were identified and 152 were selected by title screen. After abstract review, 117 were chosen for full-text review. Following full-text review, 33 articles were excluded and 21 added from references, totaling 105 articles included in our scoping review.

RESULTS

AA reduces pain severity in patients with both acute and chronic pain. The best studies in the acute settings have occurred in the peri-operative setting where sham AA is employed, multiple sessions of AA are given, and medication dosing is carefully monitored. In these cases, AA reduced pain and post-operative medications. In patients with chronic pain, multiple sessions of AA resulted not only in pain relief but also in improvements in function and disability. Literature suggests that AA works through multiple mechanisms with the most compelling data coupled to the autonomic nervous system and neuroendocrine system. Curriculums designed to teach AA and aid in implementation have been published.

CONCLUSION

AA is an accessible, effective means of pain relief. AA is relatively straightforward to learn, and protocols and curriculums exist to teach healthcare professionals this valuable skill. Overcoming implementation barriers, including patient education, are essential next steps.

Mapping the clinical practice of traditional, complementary and integrative medicine in oncology in Western countries: A multinational cross-sectional survey

BACKGROUND

Many cancer patients seek adjunctive therapies to biomedical cancer treatments at some point of their disease trajectory. While acupuncture is increasingly recommended by leading oncological associations, limited evidence exists concerning the evidence-informed practice and adherence to current guidelines of traditional complementary and integrative medicine (TCIM) practitioners treating cancer patients.

METHODS

An international online-survey assessed the demographical data, clinical practice, and sources of information used by TCIM practitioners in Austria, Germany, United States of America, Australia, and New Zealand.

RESULTS

In total, 404 respondents completed the survey, of which 254 (62.9%) treated cancer patients. Most practitioners were acupuncturists and herbalists (57.1%), had (16.8 ± 9.9) years of clinical experience and see a median of 2 (1, 4) cancer patients per week. Breast cancer (61.8%) is the most common cancer type seen in TCIM clinics. Adjunctive TCIM treatments are frequently concurrent with the patient's cancer specific treatment (39.9%), which is also reflected by the main goal of a TCIM treatment to alleviate side effects (52.4%). However, only 28.0% of the respondents are in contact with the treating oncologist. According to the respondents, pain is most effectively treated using acupuncture, while herbal medicine is best for cancer-related fatigue. TCIM practitioners mostly use certified courses (33.1%) or online databases (28.3%) but often believe that experts are more reliable to inform their practice (37.0%) than research publications (32.7%).

CONCLUSION

Acupuncturists and herbalists commonly treat cancer patients. Most practitioners use TCIM as an adjunct to biomedicine as supportive care and use it largely in accordance with current oncological guidelines.

PLEASE CITE THIS ARTICLE AS

Huemer M, Graca S, Bitsche S, Hofmann G, Armour M, Pichler M. Mapping the clinical practice of traditional, complementary and integrative medicine in oncology in Western countries: A multinational cross-sectional survey. J Integr Med. 2024; 22(1): 64-71.

Development and Assessment of an Abbreviated Acupuncture Curriculum for Pediatricians

OBJECTIVE

Acupuncture has been shown to improve pain and other health outcomes in children and is well tolerated. However, use of acupuncture by pediatric medical providers is rare, in part due to the cost and time associated with formal training. We aimed to develop an abbreviated acupuncture curriculum and assess its impact and acceptability with academic pediatricians.

METHODS

In this pilot study, pediatricians received instruction in 2 acupuncture protocols for treating acute and chronic pain (Battlefield Acupuncture and Four Gates) during a 10-hour course developed by board-certified medical acupuncturists. Learning methods included an online module with videos and articles, 2 live workshops, and additional home practice. Participants completed a skills-based exam and pre- and post-tests measuring knowledge and attitudes about acupuncture treatment.

RESULTS

Forty-five physicians (divided among 3 cohorts) began the acupuncture training course, and 38 (84.4%) completed all components. The course significantly increased participants' perceived efficacy of acupuncture for acute and chronic pain. Participants showed significant improvement in acupuncture knowledge. All participants agreed that the course would influence their current medical practice, and all participants felt confident utilizing basic acupuncture. Additionally, all participants indicated that they would recommend the abbreviated acupuncture curriculum to a colleague.

CONCLUSIONS

Pediatricians became proficient in 2 acupuncture protocols with a 10-hour curriculum and found the format and content highly acceptable. Future plans include studying acupuncture implementation and expanding the course to other departments and institutions.

The Acupuncture and Telehealth Survey: A Cross-Sectional Survey Exploring Early COVID-19 Impacts on the Acupuncture Profession

Introduction: As the COVID-19 pandemic continues to impact workforces in the United States, the Acupuncture and Telehealth Survey was released to assess the acupuncture profession's use of telehealth and workforce response to a changing regulatory landscape. Methods: An online cross-sectional survey of licensed acupuncturists in the United States was conducted in May 2020 for 4 weeks. Novel online recruitment strategies were successfully implemented including social media pages, digital media marketing, and webinar presentations. Statistical analyses were used to ascertain varying impacts on acupuncturists with telehealth training, and the use of online health care platforms, stratified by age, and history of licensure. Results: One thousand forty-five respondents from 46 states completed the survey. The majority of respondents noted a significant reduction in working hours regardless of telehealth training history (mean -18.7 h/week, p < 0.001, 95% confidence interval [-19.5 to -18.0]); however, acupuncturists managing patients online reported a lesser magnitude of impact (mean -17.3, p = 0.004). Respondents noted stress, immune support, and pain as the most common conditions managed through telehealth. Acupuncturists using telehealth primarily educated patients on nutrition- or herbal-based therapies and acupressure techniques, similar to acupuncturists managing suspected or confirmed COVID-19 cases. Although only 21% of acupuncturists reported receiving telehealth training, 38% were providing telehealth, and 13% were considering it in the future with concerns for quality patient care. Discussion: Acupuncturists' working hours were significantly reduced during the COVID-19 pandemic although many pivoted to a variety of online health care techniques and profession-specific modalities for continued patient care. This effect could be minimized by the use of telehealth platforms, necessitating adequate training on telehealth in the acupuncture profession.

Acupuncture for Pediatrics: An Educational Initiative

Objective

With the ongoing opioid crisis, the Centers for Disease Control and Prevention recommends nonpharmacologic therapies (e.g., acupuncture) for treating pain. Multiple agencies, such as the National Institutes of Health and World Health Organization, recognize acupuncture's effectiveness for treating pain, but acupuncture education for providers is scarce. A Workshop to Introduce Acupuncture for Pediatrics (AcuPeds-Workshop) was developed with support from American Academy of Pediatrics to educate providers. Additional funding was given by the Virginia Apgar Academy to evaluate the effects of attending this workshop.

Materials and Methods

This prospective study used Immediate and 1-Month Post-Workshop (PWS) surveys. The AcuPeds-Workshop components included: history; a literature review; videos of patients receiving acupuncture; and hands-on experience. The workshop was presented at numerous conferences. Attendee survey completion was voluntary.

Results

Of 327 attendees, the majority were female, non-Hispanic, and were physicians. At baseline, attendees had: heard of acupuncture, 96%; used it, 28%; and/or had a prior lecture, 13%. In the Immediate-PWS: 97% reported an increase in their knowledge and understanding of the indications for acupuncture; majority correctly addressed 3 clinical application scenarios and contraindications. With respect to attitude: 85% would use acupuncture for themselves and 88% would use it for patients. More than 80% rated the workshop components as useful or very useful. In the One-Month-PWS: majority addressed the same 3 clinical scenarios and contraindications correctly, and 11% considered referring patients for acupuncture.

Conclusions

Attendance at this AcuPeds-Workshop had a positive impact on attendees' knowledge, application of, and attitude about acupuncture. This workshop supports efforts to educate medical providers on this nonpharmacologic pain therapy.

Auricular acupressure and auricular acupuncture as an adjunct for pain management during first trimester aspiration abortion: A randomized, double-blinded, three-arm trial

OBJECTIVES

To measure pain and anxiety during first trimester uterine aspiration when using auricular acupressure or acupuncture as an adjunct to usual care.

METHODS

This randomized, double-blinded, three-arm trial enrolled patients undergoing an aspiration procedure for an induced abortion, a miscarriage, or other abnormal intrauterine pregnancy. Trial participants received auricular acupressure, auricular acupuncture, or placebo immediately prior to their procedures. The study began with 1:1:1 randomization, but later overenrolled into the acupressure group after providing retraining for greater fidelity to that intervention. All participants received ibuprofen and a paracervical block. Participants reported pain and anxiety levels via visual analog scores (0-100). Our analysis compared pain scores of those receiving acupressure versus placebo, and those receiving acupuncture versus placebo.

RESULTS

We randomized 177 participants over nine months and excluded data from four participants. We analyzed data from 70 participants who received acupressure, 51 who received acupuncture, and 52 who received placebo. The groups had similar baseline characteristics, including baseline pain and anxiety scores. For acupressure, acupuncture, and placebo groups, respectively, immediate post-procedure median pain scores were 50, 55, 47.5 (p = 0.88); maximum pain scores during the procedure were 77, 79, 79.5 (p = 0.96); postprocedure anxiety scores were 26, 28, and 21 (p = 0.47). The acupressure group results were similar before and after retraining.

CONCLUSIONS

Receiving auricular acupressure or acupuncture did not result in lower pain or anxiety scores among women undergoing vacuum aspiration compared to a placebo group.

IMPLICATIONS

The results of this trial were null, thus differing from our previous study that had shown a benefit from auricular acupuncture. Given the conflicting results, incorporating these acupuncture techniques into abortion practice would be premature.

Lessons Learned in Teaching Battlefield (Ear) Acupuncture to Emergency Medicine Clinicians

Background: Acupuncture, in general, is being proclaimed as an alternative analgesic amid the opioid crisis, and along with this, within emergency departments (EDs) there is a specific interest in a form of ear acupuncture called Battlefield Acupuncture (BFA). It is expected that BFA will be used more widely in emergency medicine as it is easy to learn and can be applied both promptly and easily. Teaching programs will be required to sustain this increased demand and upskill emergency clinicians in this skill. Objectives: This article provides experiences and recommendations, based on faculty experiences from teaching BFA in Australia to ED clinicians combined with formal participant feedback. Main Points: BFA courses were adjusted to suit ED doctors and nurses, along with their unique case mix and associated challenging environment. The content of the BFA courses included evidence, pain indications, contraindications, application, safety, mechanism of action, and how to negotiate barriers of credentialing. Workshops used the latest and most effective teaching methods that encompassed problem-based learning, infotainment, simulation, "four stage skills teaching," and "teaching on the run." Conclusion: It is hoped that the experiences gained, and lessons learned in educating this new frontier of BFA to emergency clinicians will assist others in teaching BFA and its related techniques as a viable analgesic alternative in emergency medicine.

Training hour requirements to provide acupuncture in the United States

Introduction:

The National Academy of Medicine recommends, and Joint Commission requires, offering non-pharmacologic approaches to pain management, including acupuncture, to reduce opioid overuse in the United States. This study describes 2019 state training requirements to evaluate how they represent opportunities and barriers to increasing access to acupuncture.

Methods:

We searched publicly available databases to identify Acupuncture Practice Acts and additional statutes and regulations pertaining to acupuncture training requirements on state licensure board websites. We then extracted state-specific acupuncture training requirements for individuals with and without a healthcare-related professional license.

Results:

Thirty-three states allow physicians to provide acupuncture without requiring any additional training requirements, 11 states and the District of Columbia (DC) require 200–300 training hours, and three require physicians to obtain a separate acupuncture license. Three states have no regulatory agency ruling. Forty states require non-healthcare professionals to complete an accredited program of more than 1900 h and pass an examination. Twenty-three states have an Acupuncture Detoxification Specialist designation allowing individuals without a clinical professional license to provide auricular acupuncture for substance use disorder treatment after a 70-h training course.

Discussion:

State-level training requirements are intended to increase safe and effective care, but variations represent a potential barrier to increasing the number of acupuncture providers in the United States. Allowing non-physician medical professionals to complete reduced training requirements for specific indications could be a model to increase access to acupuncture. The influence of training requirements on acupuncture access and opioid overuse needs examination.

Integrating complementary medicine in the perioperative period: a simple, opioid-sparing addition to your multimodal analgesia strategy?

The current US opioid health-related crisis underscores the importance for perioperative physicians to optimize various approaches to pain management. Multimodal techniques and enhanced recovery after surgery (ERAS) protocols are frequently cited as the most effective strategies for improving the experience of pain and reducing opioid exposure. Complementary medicine (CM) techniques, while frequently shown to be effective at reducing opioid and other pharmacologic agent use, are rarely discussed as part of these multimodal strategies. In general, CM therapies are low-cost with minimal associated risk, making them an ideal choice for incorporation into ERAS and other opioid-sparing protocols. In this Daring Discourse, we discuss the benefits and challenges of incorporating CM therapy into anesthetic practice. We hope that anesthesiologists can become more familiar with the current evidence regarding perioperative CM therapy, and begin incorporating these therapies as part of their comprehensive multimodal approach to perioperative pain management.

Evaluating the international standards gap for the use of acupuncture needles by physiotherapists and chiropractors: A policy analysis

BACKGROUND

Acupuncture needles have become an increasingly-popular treatment tool used by multiple health professions. However, the World Health Organization (WHO)'s 1999 training guidelines for acupuncture address only medical doctors and licensed acupuncturists, leaving a gap as to appropriate training standards for other professions.

AIMS AND METHODS

With reference to an extensive document analysis, and interviews with seventeen acupuncture educators from across several professions in Ontario, Canada, this work uses a critical qualitative policy analytic approach to: a) present a comprehensive account of statutory training requirements for acupuncture-needling physiotherapists and chiropractors in the United States, Canada, and Australia; and b) evaluate competing stakeholder discourses pertaining to recent related controversies.

RESULTS

A wide range of educational requirements are evident across the jurisdictions under study (most below the 200-hour WHO guideline for physicians); and there is considerable disagreement among stakeholders as to what constitutes sufficient training in various forms of acupuncture, including 'dry needling'. Organizations defending brief post-graduate training for needling physiotherapists and chiropractors are generally associated with these two professions, and contend that their 'dry needling' practices differ substantially from traditional acupuncture. Characterizing such brief training as insufficient, opportunistic and unsafe, and 'dry needling' as a subset of acupuncture practice, are the voices of all acupuncture educators interviewed, as well as professional organizations representing physicians, licensed acupuncturists, and some physiotherapists and chiropractors.

DISCUSSION AND CONCLUSION

Critiquing claims on both sides of the debate, this work calls for the development of independent, international safety-geared training guidelines that explicitly address the recent, evidence-informed trend towards biomedicalized acupuncture needling. Findings also suggest a need for additional research regarding the current shift towards overlapping-rather than exclusive-health professional practice scopes in industrialized countries.

Battlefield Acupuncture Training in Residency: A Course That Gets to the Point

Objective: Health care providers and patients in the United States have limited experience with acupuncture. A 2007 U.S. Health survey showed that 6.5% of people reported ever using acupuncture and that most them sought relief from pain. Yet, acupuncture was also used as a preventive modality to promote overall health. This study was conducted to determine if a single training session of Battlefield Acupuncture (BFA) was effective and how the session influenced residents' opinions on incorporating BFA training into residency programs. Materials and Methods: This study was conducted at a single, Physical Medicine and Rehabilitation residency program with 18 PGY2-PGY4 level residents. They were given 3-hour didactic lecture by a certified BFA instructor and then a hands-on demonstration. During the demonstration, each participant verified that he or she knew how to place 5 BFA needles. The participants were also surveyed about incorporating BFA training into residency programs. Results: After the training, 12 of the 18 participants responded to the survey. A majority of those who responded disagreed that their choice for a specific residency program would be affected by whether the program offered BFA certification. More participants than not recommended incorporating BFA into other residency program curricula. Most participants stated that that a one-time didactic and training session was adequate for learning BFA. Conclusions: Resident-physicians training in BFA techniques is effective. Residents had favorable attitudes toward this treatment and a minority intended to use the technique in their practice. BFA training can be incorporated easily in residency curricula.

Distribution of licensed acupuncturists and educational institutions in the United States at the start of 2018

This study was conducted to identify the approximate number and density of actively licensed acupuncturists, as well as the number of schools in acupuncture and oriental medicine (AOM) by January 1, 2018 in the United States (U.S.). We contacted the appropriate department governing acupuncturists, such as the Board of Acupuncture or Board of Medicine, etc. in each state and U.S. territories, to collect the data. We also conducted online license information searches in order to collect the most accurate numbers of licensed acupuncturists, especially for those states in which a board could not be reached. We found that the number of actively licensed acupuncturists as of January 1, 2018 in the U.S. was 37,886. The ten states with the largest number of acupuncturists (28,452 or 75.09% of the U.S. total), in order by total, included California, New York, Florida, Colorado, Washington, Oregon, Texas, New Jersey, Maryland and Massachusetts. The number of practitioners was greater than 1000 for each of these states. Among them, the largest three were California (12,135; 32.03%), New York (4438; 11.71%) and Florida (2705; 7.13%). These three states accounted for more than half of the overall total. The number of total licensed acupuncturists has increased 257% since 1998. The overall acupuncturist density in the U.S. - measured as number of acupuncturists per 100,000 - was 11.63 (total number of licensed acupuncturists: 37,886, divided by the total population: 325,719,178 at the start of 2018). There were 20 states with an acupuncturist density of more than 10 per 100,000 population. Hawaii (52.82) was the highest, followed by Oregon (34.88), Vermont (30.79), California (30.69) and then New Mexico (30.27). There were 62 active, accredited AOM schools which altogether offered 100 programs: 32 master degrees in Acupuncture, 53 master degrees in Oriental medicine, 13 postgraduate doctorate degrees and 2 entry-level doctorate degrees. Among these active accredited schools, institutions in the West and East Coast states comprised 77.42% of the national total. California, Florida, and New York represented 41.94%. There were 48 jurisdictions (47 States and the District of Columbia) with acupuncture practice laws in place. States without acupuncture laws included Alabama, Oklahoma and South Dakota. The data suggests that acupuncture profession has steadily grown in the United States.

Practice Drift: Are There Risks When Integrative Medicine Physicians Exceed Their Scope?

Editor´s Note: This is the third commentary from the JACM column partnership with the Osher Collaborative for IntegrativeMedicine. These quarterly columns from leaders of the seven prominent academic centers that constitute the Collaborative are meant to stimulate and enliven thinking about the paradigm, practice, and policy to advance integrative health. In this column, two members at the Osher Center for Integrative Medicine in Chicago, Illinois and San Francisco, California, take on a challenge pioneering field face as they move from the Wild West into professional formation. Their focus is on the mosaic of integrative practices of medical doctors. The lead author hails from an integrative medicine base that is known for its clinical program. Osher Northwestern executive director Melinda Ring, MD, FACP, Clinical Associate Professor of Integrative Medicine, is also a member of the Board of Directors of the American Board of Integrative Medicine, that has set the prevailing standard for board certification. Ring´s coauthor, Sandy Newmark, MD, FAAP, holds the position of Osher Foundation Endowed Chair in Clinical Programs in Integrative Medicine at the UCSF Osher Center. Newmark is also head of that Center´s Pediatric Integrative Neurodevelopmental Program. -John Weeks, Editor-in-Chief, JACM.

Acupuncture's Role in Solving the Opioid Epidemic: Evidence, Cost-Effectiveness, and Care Availability for Acupuncture as a Primary, Non-Pharmacologic Method for Pain Relief and Management-White Paper 2017

The United States (U.S.) is facing a national opioid epidemic, and medical systems are in need of non-pharmacologic strategies that can be employed to decrease the public's opioid dependence. Acupuncture has emerged as a powerful, evidence-based, safe, cost-effective, and available treatment modality suitable to meeting this need. Acupuncture has been shown to be effective for the management of numerous types of pain conditions, and mechanisms of action for acupuncture have been described and are understandable from biomedical, physiologic perspectives. Further, acupuncture's cost-effectiveness can dramatically decrease health care expenditures, both from the standpoint of treating acute pain and through avoiding addiction to opioids that requires costly care, destroys quality of life, and can lead to fatal overdose. Numerous federal regulatory agencies have advised or mandated that healthcare systems and providers offer non-pharmacologic treatment options for pain. Acupuncture stands out as the most evidence-based, immediately available choice to fulfil these calls. Acupuncture can safely, easily, and cost-effectively be incorporated into hospital settings as diverse as the emergency department, labor and delivery suites, and neonatal intensive care units to treat a variety of commonly seen pain conditions. Acupuncture is already being successfully and meaningfully utilized by the Veterans Administration and various branches of the U.S. Military, in some studies demonstrably decreasing the volume of opioids prescribed when included in care.