Discussion
The goals of this study were 2-fold. First, we sought to evaluate the feasibility and acceptability to patients and clinicians of offering acupuncture for chronic pain in the urban community health center setting, where it has rarely been available in the past. As we report elsewhere, we identified many patients with substantial chronic pain and related disability, as well as great enthusiasm among clinicians and patients for acupuncture. We also have demonstrated a high level of engagement with treatment among this patient population, with more than two thirds of our participants attending ≥5 acupuncture treatment sessions. This suggests that, despite a lack of familiarity with the discipline and the many barriers to regular attendance experienced by patients in this setting, patients are motivated to incorporate acupuncture into their care in a serious and committed fashion.
Our second goal, and the focus of this report, was to evaluate the effectiveness of acupuncture in treating chronic pain in this setting. Here we were able to reach 2 important conclusions new to the literature on this subject. First, acupuncture offered in the primary care community health center setting to an ethnically and racially diverse and socioeconomically underprivileged population with moderate to severe chronic pain is associated with a clinically and statistically significant reduction of pain in more than 30% of subjects. Most clinical trials of acupuncture to date have not delivered the service in the primary care setting, and to our knowledge none have focused exclusively on a medically underserved, community health center–based population. Given the challenges primary care doctors face in the treatment of chronic pain, particularly with new concerns being raised regarding the use of narcotic medications, and the overall safety of acupuncture as a treatment, this finding has potentially great importance in the management of pain in this setting. Acupuncture also is significantly associated with improved functional status among patients with a high degree of baseline disability.
Second, we were able to demonstrate this level of effectiveness in a population with difficult-to-treat pain using student acupuncturists who were available at no cost to the clinical sites or the patients. Because the one-on-one delivery model most common in the United States is extremely expensive to deliver, cost has been a major barrier to providing acupuncture to uninsured or underinsured patients without private financial resources. The model developed and tested in ADDOPT—using student acupuncture teams under the supervision of acupuncture faculty as part of their clinical training—has potential as a means to provide this clinical service to underserved patients. Almost every major urban area in the United States has at least one acupuncture training program, and many of these schools seek clinical training sites within conventional health care settings where their students can gain experience. Critics may argue that the acupuncture care provided by students is of slightly lower quality than that provided by more experienced practitioners. This could explain why only 32% of our participants experienced 30% or greater reduction in pain score (compared with the 40% to 50% response rate seen in many studies). Yet the fact that this delivery model makes acupuncture available where it would otherwise not be feasible makes it an important approach to consider for community health centers interested in adding acupuncture to their options for chronic pain treatment.
Limitations
Several limitations related to intervention delivery and study design should be acknowledged. Our delivery model involved supervised students, with related consequences. Constraints of the academic calendar resulted in more turnover of clinicians and breaks in treatment course not typical of care in other settings. Although the preceptors were highly experienced, the varying skill levels of student acupuncturists could have influenced outcomes. However, our design did allow for an individualized approach to treatment that more accurately reflects real-world acupuncture treatment than the fixed point protocols often used in clinical trials.
With regard to study design, in the absence of a randomized trial, we cannot say that the improvements we saw were specifically due to acupuncture. For example, it is possible that omitted variables, such as other concurrent treatment for pain, differential use of medications (both prescribed and over the counter) could have contributed to the differences seen. There was also substantial variation in "dosage": the number of acupuncture treatments varied widely between patients. The exclusion of variables such as these, and because not all patients received the planned dosage, may result in misestimating the magnitude of the effect.