Acupuncture for analgesia in the emergency department: a multicentre, randomised, equivalence and non-inferiority trial

To the Editor:

The conclusions made by Cohen and colleagues1 can be challenged on the basis of study design and results. A significant flaw in the design is that of all patients not excluded due to additional medical problems, 38% of potential study participants declined to be included, possibly because they were not prepared to be assigned to the acupuncture-only arm. This flaw introduces a critical bias when analysing the 62% who did participate, as it is reasonable to assume that they are statistically more inclined to experience a placebo benefit from acupuncture and more likely to be positive at 48 hours about repeating this therapy.

Even with this bias, however, the results of the study do not support a broad interpretation of non-inferiority, given that 39% of acupuncture-only patients required rescue therapy at or after one hour, compared with 22.5% of pharmacotherapy-only patients. In the context of an emergency department (ED) and patients with mean verbal numerical rating scale score of 8.5 at presentation, this difference in pain reduction and satisfaction with the initial therapy during the first hour of treatment should render the acupuncture-only option unacceptable.

The authors have selectively and speculatively interpreted their data to support their enthusiasm for acupuncture. Results for patients with migraine are given minimum discussion or reference in the conclusions. The inferior performance of acupuncture-only patients’ willingness to repeat the therapy at one hour is dismissed as being influenced by patients’ concerns about length of stay and transport arrangements, whereas they indicate that the same parameter at 48 hours is more meaningful. I suggest that the results at one hour more accurately reflect a patient’s experience of their pain and desire for abatement, whereas the improved satisfaction at 48 hours is the result of shifted perspective following self-resolution — in a selected patient population with an existing positive bias for acupuncture.

The authors’ suggestion that acupuncture use in EDs would reduce opioid addiction is an opportunistic grab at exploiting popular sentiment among people who do not understand the causes and parameters of this serious problem. This article does not support diversion of resources towards acupuncture use in EDs or a change in evidence-based treatment protocols in emergency medicine.