The Affordable Care Act (ACA) attempted to create wider access to health care services for patients in America and reframed some of the guidelines that insurance companies and other payers must oblige when evaluating coverage of services by acupuncturists and other alternative medical providers. Section 2706 of the ACA, also known as “Nondiscrimination in Health Care,†aimed to create professional parity for state-licensed providers like acupuncturists who render services within their legal scope of practice. By mandating coverage of these services and eligibility for reimbursement for treatment of health conditions covered in an insurance plan, state-licensed heath care professionals can no longer be excluded from insurance plans on the basis of their profession. Section 2706, however, does not create parity in terms of reimbursement rates, which creates a loophole for insurers that concerns many acupuncturists. Also, in states where professional licensing of some alternative medical providers is not in place, coverage may still be denied for services that may be covered elsewhere. It is clear that the nondiscrimination provision is a start to addressing egalitarian recognition for some alternative health care professionals, but there is still much to address to ensure interpretation of this provision is not tailored to the needs of insurers instead of to patients and related providers. Section 3502 of the ACA, also was an attempt to legitimize acupuncture and other alternative medical services through its mention of establishing interdisciplinary community heath teams that may include licensed professionals offering complementary and alternative medicine (CAM), a.k.a. complementary integrative health (CIH). This language opened the discussion of inclusion of CIH services in essential health benefits but, again, more attention will be needed to see implementation of CIH as a mainstay in the common delivery of health care in America. Regardless, these provisions do favor the recognition and use of acupuncture and other services, which have been historically marginalized in the insurance marketplace. This is surely a positive start to mainstream integration.
Monthly Archives: July 2018
Acupuncture for Heroes and Seniors Act of 2017
The Acupuncture for Heroes and Seniors Act of 2017, if passed, would expand the treatment of veterans, U.S. Armed Forces military personnel, and their dependents to include acupuncture services for many health concerns without the need for a referral. The significance of this bill on a national level is that it would provide a new baseline for standards of care that recognize acupuncture as an essential benefits for the populations mentioned in addition to those who receive Medicare. Also, by including licensed acupuncturists with medical doctors certified in acupuncture as “qualified†providers, this bill elevates the reputation of our profession on the national stage, lending credibility and perceived value to the training that licensed acupuncturists receive by the public and other established medical professionals.
By creating an overarching recognition of the merits of our profession in federally funded health care, this has the potential to affect legislation on a state level, especially in states where laws for the practice of acupuncture are not clearly defined or lacking. A nationally accepted bill may force change in these states to advance the status of licensed acupuncturists to be accepted as respected medical practitioners. In states where acupuncture laws are more progressive, this bill could be helpful to protect and expand our scope of practice as acupuncture services become more of a mainstay in the current system.
To date, the development of acupuncture in the military has affected my practice in an indirect way as it has helped to provide a reputable source of acceptance that filters into the mainstream media and perception of acupuncture by the conventional medical institution. I live in Manhattan, right around the block from the local VA hospital and have volunteered there for several years. Even so, I have not had the opportunity to treat veterans with acupuncture. In the past, I’ve spoken to the head of the acupuncture department there who mentioned that there is a long waitlist to receive acupuncture for pain management yet they do not refer out to licensed acupuncturists, despite the demand and positive treatment outcomes recorded. Recent developments with the VA Mission Act of 2018 may be enough on it’s own to increase acupuncture services offered by licensed acupuncturists to veterans, however, the passing of the Acupuncture for Heroes and Seniors Act of 2017 will place a focus specifically on acupuncture and will open up a clearer path for me and fellow licensed acupuncturists to participate in treating veterans.
Acupuncture for postoperative pain
Acupuncture can be helpful in postoperative care after back surgery or joint replacement, specifically for patients interested in or recommended for non-pharmacologic pain management.
Acute pain resulting from surgical trauma can present significant challenges by delaying the ability of patients to move about and begin to perform rehabilitation exercises that are important to help reduce the development of scar tissue, improve range of motion, and increase the chances for a successful recovery. In addition, patients who undergo spinal and joint replacement surgery are at greater risk for developing a deep vein thrombosis and their risk may increase if pain continues to limit physical movement after surgery.
While opioid medication are typically effective to reduce pain, they also can cause unwanted side effects like nausea, vomiting, dizziness, sedation, pruritus, constipation, and urinary retention. These can further delay recovery and lead to a decreased sense of satisfaction with the surgical procedure by the patient.
Acupuncture can offer an alternative to opioids and is commonly uses for pain management. It can provide a safe and effective non-pharmacologic option to manage acute postoperative pain. Several related systemic reviews of randomized controlled trials have been conducted on this subject and found acupuncture to be effective in reducing post-surgical pain intensity and lead to a lower incidence of opioid-related side effects when used alongside conventional interventions for pain. Citations for these reviews are included at the end of this article. One meta-analysis specifically summarizes the effectiveness of acupuncture treatment for pain reduction after back surgery.
Further studies have shown the pain modulating effects of acupuncture to be due to its ability to augment the peripheral and central nervous system to inhibit pain-signaling pathways and increase the threshold for pain tolerance. Acupuncture has been recognized to trigger the release of specific neuropeptides including beta-endorphins, enkephalins, and dynorphins to elicit a self-healing response and create analgesia.
When being used for surgical pain, acupuncture has been found to be especially helpful when received within 24 hours before surgery as well as within the first week after surgery. Additionally, acupuncture can address pain or debility that may occur during and after the rehabilitation phase and can be useful in a multi-modal approach for patients experiencing lowered signs of progress with standard care alone.
Acupuncture for Postoperative Pain Research Citations
Systemic Reviews and Meta-analyses
Liu X.L., Tan J.Y., Molassiotis A., Suen L.K., Shi Y. (2015). Acupuncture-point stimulation for postoperative
 pain control: A systematic review and meta-analysis of randomized controlled trials. Evidence-Based Complementary and Alternative Medicine, 2015;2015:657809. http://doi.org/10.1155/2015/657809
Sun Y., Gan T.J., Dubose J.W., Habib A.S. (2008). Acupuncture and related techniques for postoperative pain: a systematic review of randomized controlled trials. British Journal of Anaesthesia, 101(2):151-160. http://doi.org/10.1093/bja/aen146
Wu M.S., Chen K.H., Chen I.F., Huang S.K., Tzeng P.C., Yeh M.L., Lee F.P., Lin J.G., Chen C. (2016). The efficacy of acupuncture in post-operative pain management: A systematic review and meta-analysis. PloS One, 11(3). http://doi.org/10.1371/journal.pone.0150367
Acupuncture Mechanism of Action Studies
Mayor D. (2013). An exploratory review of the electroacupuncture literature: clinical applications and endorphin mechanisms. Acupuncture in Medicine, 31(4):409-15. s
Wang J.Q., Mao L., Han J.S. (1992). Antinociceptive effects induced by electroacupuncture and transcutaneous electrical nerve stimulation in the rat. Int J Neurosci. 1992; 65: 117–129.
Zhao Z.Q. (2008). Neural mechanism underlying acupuncture analgesia. Progress in Neurobiology, Aug;85(4):355-75. http://doi.org/10.1016/j.pneurobio.2008.05.004
Is acupuncture painful? The concept of deqi
There is a range of different styles that have been developed throughout the history of acupuncture that incorporate a variety of different needling techniques. While some, like seen in Japanese acupuncture, use a very superficial insertion of needles just under the skin with an extremely gentle stimulation of the point locations, it has become a commonly accepted practice in Traditional Chinese Medicine to elicit a strong needle sensation experienced by the patient at each point location by inserting a needle to the desired depth (based on anatomical location) and manipulating the needle manually by lifting and reinserting it or by twirling the needle.
This can be felt by patients in a various ways and described as a soreness, numbness, distension, heaviness, or pain. Yes, pain. Acupuncture has long been touted as not being painful but this is not always the case. This may be due to this technique being central to the clinical practice of acupuncture for over 2000 years that this strong needle sensation was recognized to have unique therapeutic value and experienced separate from pain. For many Americans, though, who are new to acupuncture, acupuncture can be described as being painful.
The needling sensation can also be observed by the practitioner as a gripping quality around the needle when tugged, an involuntary twitching of the muscles, and sometime redness of the skin around the needle site.
If you’ve read any research trials that utilize acupuncture treatment, you may have seen this technique described in the Methods section as “needling sensation, “acupuncture with stimulation,†or sometimes by the pinyin term “deqi†which is commonly translated as “obtaining the vital energyâ€. Interestingly, researchers have also studied this needling sensation with neuroimaging using fMRIs and have found stronger activation of different regions of the brain than when using only tactile superficial stimulation of acupuncture points.
In the scientific community, this local sensation felt by patients has long been associated with stimulation of afferent nerve fibers but more recent research suggests that involvement of the deformation of connective tissue through acupuncture may play a strong part with the mechanism of acupuncture. Local vasodilation also results from needle stimulation along with the local release of substances like histamine, nitric oxide, prostaglandins, and many others which are currently being studied for their relationship in explaining how acupuncture works.
Fanaticism: Addressing a common response to the topic of acupuncture, “I don’t believe in it.â€
Enthusiasm and passion are qualities often seen as being supportive to achieving goals and explaining ideas. Increased interest in any subject manner boosts people’s engagement level when speaking to others and often makes their message richer with details and personal insights. Zeal commonly has an interdependent relationship with a person’s beliefs and behaviors. Extreme enthusiasm can correlate with having a more defined belief system, yielding self-affirming behaviors and a use of language that reinforces faith in defined ideas. When this narrows tolerance for other ideas that may challenge those established, fanaticism can limit people’s discourse on any subject in view. Defensive arguments, judgments, and blind faith can grow while a person clings to their ideas as being infallible and integral to their perception of self-identity.
In the context of an inter-professional health care team, there is fanaticism in both the conventional and alternative communities. Fanaticism reinforces independence, which can be counter-productive to collaboration and the exchange of ideas from all members of the team. For acupuncturists interested in integration, I’m not sure if there’s clarity that we are even included yet on the “team†by the conventional medical community to reputably participate in the exchange of ideas and potentially be heard by their members.
As the position to have acupuncture firmly instated into our modern health care system is gaining traction, the focus seems to be about growing the amount of evidence in the form of data to carry the decision into common acceptance. However, for fanatics on both the conventional and alternative sides whose belief systems may be influencing their critical analysis of the efficacy of acupuncture, maintaining an impartial and inclusive perspective in our language and actions will be helpful to build bridges towards the open-mindedness that will be required, despite meeting the undefined threshold for a conclusive amount of data.