Letter 1
I am writing to voice my concern after reading the article by Dr Tim Williams on chronic pain.
Although Dr Williams is obviously experienced in writing about the drug treatment of pain, he seems to have less experience with acupuncture and other modalities.
NICE guidelines in 2009 for chronic back pain recommend a structured exercise programme, acupuncture or a course of manual therapy, according to patient preference, as an alternative to drug treatment. NICE guidelines for the treatment of chronic headache 2012 state that a course of acupuncture should be offered as an alternative to gabapentin according to patient preference.
Dr Williams claims that acupuncture is extremely expensive as an outpatient procedure – approximately £200 a session – and that there are no reliable selection procedures.
In fact, most pain clinics and many physiotherapy clinics offer acupuncture for far less than £200 a session and many patients do respond.
As a GP and practising acupuncturist, I feel sad when I see patients on escalating drug treatments who come for acupuncture at a late stage when their joints have worn and muscles atrophied, rendering this treatment less effective.
Many have had no exercise regimes in their management and this is also not mentioned in the article.
A recent meta-analysis of 29 high-quality randomised controlled trials using acupuncture by Vickers et al (Arch Intern Med Sept 2012) showed that in chronic back and neck pain, osteoarthritis and chronic headache, acupuncture produced a significant difference in pain levels.
From Dr Rosemary Alexander, Pinner, Middlesex
Letter 2
Dr Williams’s article on chronic pain raised interesting points, but I felt there was insufficient emphasis on the risk of opiate addiction. Interestingly there was an article on a patient addicted to prescription drugs in the same edition!
From Dr David Metson, Bracknell, Berkshire
1 Smith BH, Higgins C, Baldacchino A. Substance misuse of gabapentin Br J Gen Pract 2012; 62(601): 406–7
Dr Williams replies:
I apologise for causing Dr Alexander, and perhaps other readers, concern over my position with respect to acupuncture. Having worked in the field of chronic pain for over 10 years, I have referred a number of patients for acupuncture and some have benefited significantly. The tariff price of secondary care acupuncture is, in my opinion, a significant barrier to its use long term and needs to be addressed. Hopefully this can be done with the welcome involvement of experienced practitioners like Dr Alexander.
I’m also grateful for the additional reference to NICE guidance on the use of acupuncture in certain chronic pain conditions and I agree that this could have been included. However, I still think that predicting who will respond is difficult as with any treatment, and reducing the price of this intervention will allow finding out more palatable to commissioners.
I believe my article emphasised that I was keen for patients to use what ‘worked’ to help them function better and moving them towards self-management and getting their’ life back’, whether that was with medication, acupuncture, injection treatments, or indeed anything else. I absolutely agree that exercise is part of rehabilitation that should accompany most other interventions in chronic pain and I apologise for not including it. I am grateful for your letter for adding balance where that may have been needed, in my original article.
And thanks to Dr Metson for his letter, re-emphasising the important issue of addiction which I stated should be discussed with patients when initiating opiates, and any concerns about addiction, should be dealt with by appropriate referral to specialist support services. There is certainly significant debate about this in the chronic pain specialist world at present and this letter is very welcome.
In this article - and my previous Ten Top Tips article on chronic pain - I emphasised what I consider to be the best current advice – the British Pain Society’s Opioids for Persistent Pain: Good Practice. I would hope that adhering to these guidelines would further reduce the risks of inappropriate prescribing of strong opiates.
Dr Tim Williams is a GP and community pain specialist in Sheffield.
