The New NICE Guidelines on Low Back Pain: Bias Against Acupuncture Increases Risk to Patients

Video by: Acupuncture Now Foundation

The following is a press release by the AFPA and the ANF in response to the publication today (November 30th, 2016) of revised NICE guidelines on the treatment of lower back pain.

New NICE Guidelines on Low Back Pain: Bias Against Acupuncture Increases Risk to Patients

30th of November 2016 – Today the UK’s National Institute for Health and Care Excellence (NICE) published an update to its guidelines for the management and treatment of low back pain that removes acupuncture as a recommended treatment. This decision reverses the recommendations of the 2009 NICE committee who recommended it on the basis of robust evidence. The guidelines govern which treatments UK GPs working in the National Health Service (NHS) can offer to their patients suffering from back pain. Removing the recommendation for acupuncture means that GPs are more likely to rely on treatments such as painkillers (which are less safe than acupuncture) and exercise (which is less effective than acupuncture).1

The reversal by this UK committee stands in contrast to recommendations by research and policy institutions in countries such as the United States, Canada and Germany. These increasingly include acupuncture as a safe, effective, non-pharmacological treatment for low back-pain based on evidence that shows acupuncture outperforms usual care, and has fewer risks and side effects than commonly used pain medications. While the evidence for acupuncture’s safety and effectiveness has grown stronger since 2009, the UK committee’s reversal of position was based on a new decision to only include studies comparing real acupuncture treatment to ‘sham’ acupuncture. Sham acupuncture also uses acupuncture needles but is not considered to be an inert placebo control, and is recognised to underestimate treatment effects. Guideline developers in other countries have increasingly steered away from using these sham studies, which have limited clinical relevance for GPs and their patients.

In the UK, NICE found that real acupuncture outperformed the sham acupuncture controls, but the committee decided that the difference was just below the threshold to support a recommendation. Guideline reviews in other countries, such as one published by the Agency for Healthcare Research and Quality (AHRQ) in the United States earlier this year, found a greater difference between acupuncture and sham acupuncture control. According to the AHRQ analysis, acupuncture was the most-effective non-pharmacological treatment available for low back-pain.

All other manual therapies reviewed and recommended by NICE, such as manipulation, massage or exercise, were primarily compared to usual care and generally were not shown to be better than placebo. While the NICE committee required acupuncture to outperform sham treatment, the same requirement was not imposed on the other therapies included in these guidelines. This represents a bias in recognised guideline development practice, where great lengths are normally taken to compare treatments using the same measuring stick. NICE did not adequately justify why acupuncture alone was singled out in its analysis in this way.

The NHS spends over £300 million pounds2 treating injuries caused by NSAID (Nonsteroidal anti-inflammatory drugs) use, such as GI bleeds and heart failure, resulting in two thousand preventable deaths every year in the UK3. The new guidelines do caution that doctors should recommend the lowest dose of NSAIDs for the shortest amount of time possible. Nevertheless in the UK around 2,000 deaths a year are predicted due to NSAIDs that would not occur otherwise.3 Recommending access to acupuncture as an effective drug-free alternative to treat low back pain could lead to a reduction in the intake of harmful medications.

The updated recommendations will mean reduced choice in the UK for patients and their health care providers as they could lose access to acupuncture on the NHS when it has one of the best combinations of benefit to harm ratio of any treatment evaluated by NICE, leaving providers with less effective options that potentially may carry a greater risk. According to Professor Hugh MacPherson of the University of York, “The criteria that NICE used to evaluate acupuncture for low back pain are not the same as those used for other physical therapies, and therefore the recommendations are founded on evidence-biased medicine rather than on evidence-based medicine.”

In the Republic of Ireland, patient treatments are not constrained by NICE guidelines. However, Irish GPs may well be influenced by these guidelines to promote drug based treatments (with all their associated risks) rather than recommend acupuncture, a safer, drug-free treatment that is proven to be effective for the treatment of low back pain.

Acupuncture Now Foundation

Acupuncture Foundation Professional Association


  1. Lewis R, FLCOM NHWPF, PhD AJS, et al. Comparative clinical effectiveness of management strategies for sciatica: systematic review and network meta-analyses. The Spine Journal. 2015;15(6):1461-1477. doi:10.1016/j.spinee.2013.08.049.
  2. Moore RA, Phillips CJ. Cost of NSAID Adverse Effects to the UK National Health Service. Journal of drug assessment; 1999.
  3. Tramèr MR, Moore RA, Reynolds DJ, McQuay HJ. Quantitative estimation of rare adverse events which follow a biological progression: a new model applied to chronic NSAID use. PAIN. 2000;85(1-2):169-182.