THE PRACTICE OF ACUPUNCTURE www.nccaom.org

Acupuncture is widely practiced in eastern medicine for the diagnosis and treatment of illnesses, as well as broader prevention and well-being therapies.

What is Acupuncture?Like most broad medical disciplines, the practice of acupuncture and oriental medicine covers a spectrum of treatments, diagnostic capabilities, and patient interactions. Acupuncture is widely practiced in eastern medicine for the diagnosis and treatment of illnesses, as well as broader prevention and well-being therapies.

Specifically, acupuncture refers to the stimulation of specific points on the body, by insertion of very fine, sterile, stainless steel needles to elicit a predictable physiological response. This stimulus may also be administered to the points using mild electrical stimulation (with or without needles), pressure techniques with the hands (“acupressure”), or the application of heat by various methods. Applying pressure or needling to these points stimulates the nervous system to release certain chemicals in the muscles, spinal cord, and brain. These chemicals either change the body’s experience of symptoms, especially pain, or trigger the release of additional hormones which influence the body’s internal regulating system.

The acupuncturist’s skill at determining the appropriate points to treat is based upon their ability to accurately distinguish the presenting pattern of symptoms, knowledge of correct points to address that pattern, and understanding of the proper type of stimulus for each point. The possession of this knowledge and skills is the key distinction between a professional, specialized, certified acupuncturist and other health care providers who employ acupuncture only as a modality (stimulating points for their general effect without adjusting their choice of points to the specific patient’s need.)

Effects of AcupunctureAcupuncture treatment can be used to address a variety of symptoms in patients, as well as to promote general health and well-being as a preventative treatment. National and international authorities, including the World Health Organization, the National Institutes of Health, and the American Medical Association, have recognized the effectiveness of acupuncture as a treatment for a wide range of issues, including chronic and post-operative pain, musculo-skeletal disorders, respiratory problems, neurological disorders, mental-emotional disorders, gastrointestinal conditions, ear, eye and mouth disorders, and reproductive issues.

NCCAOM CERTIFICATION www.nccaom.org / 1

The NCCAOM was established to assure the safety and well-being of the public and to advance the professional practice of acupuncture and Oriental medicine by establishing and promoting the national evidence-based standards of competence and credentialing. Since the organization’s inception, the NCCAOM has issued more than 21,000 certificates in acupuncture, Oriental medicine, Chinese herbology and Asian Bodywork Therapy (ABT). The NCCAOM works in concert with sister organizations the American Association for Acupuncture and Oriental Medicine (AAAOM), the Accreditation Commission for Acupuncture and Oriental Medicine (ACAOM), and the Council of Acupuncture and Oriental Medicine (CAOM). Additionally, the NCCAOM has worked in recent years directly with federal agencies to establish recognition of its certification programs and its Diplomates in the federal arena, including creating a distinct classification code with the Bureau of Labor and Statistics’ Occupational Outlook Handbook.

Certified AcupuncturistsThe NCCAOM certifies 1,200-1,500 acupuncturists a year and represents almost 18,000 nationally certified practitioners. Earning NCCAOM certification indicates to employers, patients, and other practitioners that one has met national standards for the safe and competent practice of acupuncture. National board certification in acupuncture has been the mark of excellence in the profession since the inception of NCCAOM in 1982. NCCAOM® National Board-Certified Acupuncturists™, known as Diplomates of Acupuncture or Diplomates of Oriental Medicine, represent the gold standard of the profession, having completed a rigorous and comprehensive educational, training, and examination process.

NCCAOM Certification ProcessThe certification process to become an NCCAOM® National Board-Certified Acupuncturist™, is comprehensive and in-depth, in order to ensure the highest levels of professional competency. Diplomates of Acupuncture or Diplomates of Oriental Medicine are required to complete three to four academic years of education at the master’s or doctoral level, in a program accredited by the Accreditation Commission for Acupuncture and Oriental Medicine (ACAOM), the only body recognized by the U.S. Department of Education as the authority for quality education and training in the profession. Additionally, graduates of such programs must demonstrate professional competency by passing NCCAOM certification examinations, and documentation of successful completion of an in-person Clean Needle Technique course. NCCAOM Diplomates must be recertified every 4 years, in order to maintain their knowledge and performance at the highest levels of competency for acupuncture practice.

About NCCAOMThe National Certification Commission for Acupuncture and Oriental Medicine (NCCAOM) is a non-profit 501(c)6 organization established in 1982. The NCCAOM is the only national organization recognized by a majority of state governments to validate entry-level competency in the practice of acupuncture and oriental medicine through professional certification. NCCAOM certification or a passing score on the NCCAOM certification examinations are considered documentation of competency for licensure as an acupuncturist by 47 states and the District of Columbia, which represents 98% of the states that regulate acupuncture. All NCCAOM certification programs are currently accredited by the National Commission for Certification Agencies (NCCA) and carry the NCCA seal.

22 states that require NCCAOM certification in order to issue a license to practice acupuncture

CERTIFICATION FACTS

26more (and the District of Columbia) use the NCCAOM examinations as part of their licensing requirements

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Acupuncture EducationThe most important factor in achieving NCCAOM certification is completing an extensive, full-length, accredited education in acupuncture and Oriental medicine. The majority of NCCAOM Diplomates gained certification through formal education in the United States. A master’s degree in acupuncture takes a minimum of three years and 1,905 hours of training, covering acupuncture theory, clinical practice, biomedicine, ethics, counseling, patient communication, and practice management. A broader degree in Oriental medicine requires four years and 2,625 hours, covering the above disciplines as well as didactic Chinese herbal studies.

After graduation, or after completing the majority of the program and with approval from school administrators, students may apply to sit for the NCCAOM certification exams, including Foundations of Oriental Medicine, Biomedicine, and Acupuncture with Point Location, administered by NCCAOM. The content of these exams is developed by NCCAOM through regular Job Analysis surveys of the profession, in concert with a dedicated Task Force of Subject Matter Experts. International applicants who have completed accredited, full-term education programs in another country can be determined eligible for the NCCAOM examinations after getting their transcript and coursework approved by a professional credential evaluation organization.

NCCAOM Recertification and Profession MonitoringCertification for acupuncturists is an ongoing process to ensure that Diplomates continue to provide the safest, highest quality of acupuncture care. Every four years, certified Diplomates must undergo the recertification process in order to maintain their status with NCCAOM. The process includes 60 hours of Professional Development Activity, which covers various methods of continuing education. This must include at least 30 hours of re-training in the core competencies of acupuncture, at least 4 hours of safety and ethics training, including education on bloodborne pathogens, clean needle techniques, and more, as well as a continually updated CPR certification.

Additionally, the recertification process aids NCCAOM in monitoring the profession. As the only national

certification organization in the United States for the practice of acupuncture, NCCAOM acts as a safety net to confirm that providers are knowledgeable and are safe practitioners. NCCAOM continuously monitors developments in the acupuncture ecosystem, especially with regards to any adverse actions taken against Diplomates. While actions within a state may only get reported within that state, NCCAOM works to confirm that all of its Diplomates are in good standing wherever they practice – a function that states are simply not equipped to perform this surveillance for the over 30,000 licensed acupuncturists across the country.

Certification is Necessary for Patient SafetyLike any medical discipline, the safe and effective practice of acupuncture requires carefully trained professionals. NCCAOM® National Board-Certified Acupuncturists™ undergo a training and competency verification program in sharp contrast to the less rigorous acupuncture training of non-specialized health care professionals such as chiropractors, registered nurses, or even medical doctors. These other professions typically receive at most 100-300 hours of abbreviated training and treat a limited number of pain points.

NCCAOM® National Board-Certified Acupuncturists™ are also trained in standard medical history gathering, safety, and ethics, as well as the proper methods and procedures for referring patients to outside professionals and consulting with non-acupuncturist practitioners.

The majority of states in America have recognized the importance of NCCAOM certification for safe and competent practice. There are 22 states that require NCCAOM certification in order to issue a license to practice acupuncture, and 26 more (and the District of Columbia) use the NCCAOM examinations as part of their licensing requirements. Three states (South Dakota, Oklahoma and Alabama) lack an Acupuncture Practice Act, and, therefore have no licensure for acupuncturists, resulting in a lack of standards and the ability for anyone to practice without meeting safety and competency qualifications. Many of the states that have a practice act do not require license renewal for acupuncturists, making the recertification element for NCCAOM Diplomates even more essential.

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IntroductionOver the last several years, the nationwide opioid crisis has become a focus of policymakers at every level of government. According to the National Institute on Drug Abuse, more than 90 Americans die of opioid overdoses each day, not including the numerous related public health issues that stem from widespread opioid misuse. There are countless local and state government initiatives to address the crisis, and the federal government has taken steps as well.

The underlying causes of the current crisis in America are varied and persistent – there will be no “silver bullet” to reverse what has developed over decades. However, many of the proposed solutions have centered around limiting the supply and distribution of prescription pain medicine in the U.S. Doctors are being encouraged to limit opioid prescriptions and pursue alternative treatments for their patients’ pain needs. Acupuncture treatment is an effective, non-pharmacological modality with a strong evidence base to support its use for treating a variety of chronic and acute pain symptoms. Under the direction and oversight of a certification body like the National Certification Commission for Acupuncture and Oriental Medicine (NCCAOM®), who certify NCCAOM® National Board-Certified Acupuncturists™, acupuncture can and should emerge as a widely-used, powerful addition to any pain treatment care plans.

Causes and Development of the Opioid EpidemicOver the last 15-20 years, a crisis developed in the United States with the proliferation and widespread abuse of prescription opioid medications and illegal opioid drugs. Healthcare providers prescribed these medications at staggering rates, and heroin and synthetic opioids like fentanyl began to flood the illegal drug market, causing

drastic increases in addiction, overdoses and drug-related deaths. According to the National Survey on Drug Use and Health (NSDUH) carried out by the Substance Abuse and Mental Health Services Administration (SAMHSA), more than 11 million Americans misused prescription opioids in 2016 alone, and 2.1 million developed an opioid use disorder. There have been more than 300,000 opioid overdose deaths in America since 2000, and while final numbers are yet to be tallied, early data suggests that at least 64,000 overdose deaths occurred in 2016, which would mark the highest number ever recorded in the country.1

Since 1999, the number of opioid-related deaths has quadrupled.2 It is staggering that almost two-thirds of Americans have been prescribed an opioid for pain issues, that 49% report knowing someone who has been addicted to prescription opioids, and one in five Americans know someone whose opioid abuse led to their death within the last five years. In fact, for the second year in a row, the Centers for Disease Control and Prevention’s (CDC) National Center for Health Statistics found that the life expectancy in the U.S. actually dropped, largely due to the continued specter of drug overdose deaths.3

Addressing the Opioid Crisis through Non-Pharmacological Acupuncture Interventions

1 The Federal Response to the Opioid Crisis. Testimony by Dr. Elinore McCance-Katz, Assistant Secretary for Mental Health and Substance Use, Substance Abuse and Mental Health Services Administration, before the Senate Health, Education, Labor and Pensions Committee, October 5, 2017.

2 Centers for Disease Control and Prevention. Opioid Overdose: Understanding the Epidemic. August 30, 2017 (https://www.cdc.gov/drugoverdose/epidemic/index.html) 3 Kochanek, Kenneth, Sherry L. Murphy, Jiaquan Xu, and Elizabeth Arias. (December 2017) Data Brief No. 293: Mortality in the United States, 2016. National Center for

Health Statistics.

Almost two-thirds of Americans have been prescribed an opioid for pain issues, 49% report knowing someone who has been addicted to prescription opioids, and one in five Americans know someone whose opioid abuse led to their death.

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A number of factors contributed to the development of the current crisis. In the late 1990s and early 2000s, pain began to be recognized and treated by many in the medical community as a “fifth vital sign,” largely stemming from Pain Management Guidelines included by The Joint Commission (a hospital regulatory body) and the inclusion of pain-related questions in the Centers for Medicare and Medicaid Services (CMS) patient satisfaction surveys. By asking patients to rate their doctors based on their own experience of pain (and tying physician reimbursement to those surveys), CMS incentivized physicians to over-rely on opioid medications that would dull patient pain without regard for consequences.

Doctors began to prescribe opioid medications to treat a wide range of pain complaints in ever-increasing doses. Pharmaceutical companies pushed opioid drugs as safe and addiction-free, and physicians were incentivized to keep upping patient doses to treat patients who complained of pain. The massive availability of prescription opioids led many to abuse them becoming addicted even without ever using illegal drugs.

A perfect storm emerged as an influx of cheap heroin into the United States, along with the development of fentanyl and other synthetics, allowed for easy and widespread abuse of illegal opioids for the addicts.

Addressing the Opioid Crisis at the Federal Government LevelOn October 26, 2017, President Donald Trump and the then-acting Secretary of Health and Human Services, Eric Hargan, officially declared the opioid epidemic a national Public Health Emergency. The move allows the federal government to waive certain regulations and give more flexibility and independence to states utilizing federal funds for treatment, especially with regards to expanding telemedicine services. However, the declaration stopped short of a full national emergency.

In addition to the effects of the public health declaration, federal agencies in HHS, including the Food and Drug Administration (FDA), the National Institutes of Health (NIH), CDC, and SAMHSA, have continued to implement

efforts to address the crisis. These agencies are working under the direction of HHS’ five-point Opioid Strategy, released in April 2017 as an overarching framework for coordinating the federal government’s response to the crisis. Among other goals, the strategy aims to:

• Support cutting-edge research that advances our understanding of pain and addiction, leading to the development of new treatments, and identifies public health interventions to reduce opioid-related health harms; and

• Advance the practice of pain management to enable access to high-quality, evidence-based pain care that reduces the burden of pain for individuals, families, and society while also reducing the inappropriate use of opioids and opioid-related harms.

These last two points are key, as the development and promulgation of safe, effective, and widely available alternatives to drugs will be essential to the improved treatment of pain and the reduction of opioid prescriptions. Other bodies have also recognized the importance of alternative pain management in addressing the crisis.

The President’s CommissionThe final report from the White House’s Opioid Commission, released November 1, 2017, provides a wide swatch of recommendations regarding drug addiction and the opioid crisis, ranging from law enforcement solutions to the development of non-addictive pain medicines. However, the report also places a focus on the importance of developing and spreading alternative pain management strategies.4

“Chairman’s Letter: First, individuals with acute or chronic pain must have access to non-opioid pain management options. Everything from physical therapy, to non-opioid medications, should be easily accessible as an alternative to opioids… We should incentivize insurers and the government to pay for non-opioid treatments for pain beginning right in the operating room and at every treatment step along the way. In some cases, non-addictive pain medications are bundled in federal reimbursement policies so that hospitals and doctors are essentially not covered to prescribe non-opioid pain management alternatives.”

4 “Final Report,” The President’s Commission on Combating Drug Addiction and the Opioid Crisis. November 1, 2017.

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“Recommendation 19:” The Commission recommends CMS review and modify rate-setting policies that discourage the use of non-opioid treatments for pain, such as certain bundled payments that make alternative treatment options cost prohibitive for hospitals and doctors, particularly those options for treating immediate post-surgical pain… Although in some conditions, behavioral programs, acupuncture, chiropractic surgery, as well as FDA-approved multimodal pain strategies have been proven to reduce the use of opioids, while providing effective pain management, current CMS reimbursement policies, as well as health insurance providers and other payers, create barriers to the adoption of these strategies.”

“Recommendation 52:” The Commission recommends federal agencies, including HHS (NIH, CDC, CMS, FDA, and SAMHSA), Department of Justice (DOJ), the Department of Defense (DOD), the Veteran’s Administration (VA, and the Office of National Drug Control Policy (ONDCP), should engage in a comprehensive review of existing research programs and establish goals for pain management and addiction research (both prevention and treatment).”

Centers for Disease Control & PreventionThe CDC has released a number of guidelines and best practices for providers regarding non-opioid treatments for chronic and acute pain. The Centers continue to develop new materials and are working in conjunction with other federal agencies on broader guidelines. Specifically, in 2016, the CDC released the Guideline for Prescribing Opioids for Chronic Pain, which addressed official recommendations for providers dealing with pain patients.

“Recommendation 1:” Nonpharmacologic therapy and nonopioid pharmacologic therapy are preferred for chronic pain… If opioids are used, they should be combined with nonpharmacologic therapy and nonopioid pharmacologic therapy, as appropriate.”5

“Effective approaches to chronic pain should:

• Use nonopioid therapies to the extent possible.

• Focus on functional goals and improvement, engaging patients actively in their pain management.”6

The Joint CommissionThe Joint Commission is an independent organization responsible for accrediting a large proportion of the hospitals and healthcare facilities in the United States. Effective Jan. 1, 2018, the Joint Commission released updates to their Pain Assessment and Management Standards for Hospitals, largely in response to the opioid crisis and the perception that Joint Commission standards had contributed to the proliferation of opioid prescriptions in the 21st century. A number of the revised standards emphasize the importance of alternative pain management.7

“LD 04.03.13” (Leadership): Pain assessment and pain management, including safe opioid prescribing, is identified as an organizational priority for the hospital.

• “Elements of Performance (EP) 2:” The hospital provides nonpharmacologic pain treatment modalities.8

• “EP 3:” The hospital provides staff and licensed independent practitioners with educational resources and programs to improve pain assessment, pain management, and the safe use of opioid medications based on the identified needs of its patient population.9

• “EP 4:” The hospital provides information to staff and licensed independent practitioners on available services for consultation and referral of patients with complex pain management needs.”10

5 “CDC Guidelines for Prescribing Opioids for Chronic Pain – United States, 2016,” Morbidity and Mortality Weekly Report. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention. March 18, 2016.

6 “Nonopioid Treatments for Chronic Pain Fact Sheet,” U.S. Department of Health and Human Services, Centers for Disease Control and Prevention.7 “Pain Assessment and Management Standards for Hospitals,” R3 Report, Issue 11. The Joint Commission. August 29, 2017.8 Continued: “While evidence for some nonpharmacologic modalities is mixed and/or limited, they may serve as a complementary approach for pain management and

potentially reduce the need for opioid medications in some circumstances. The hospital should promote nonpharmacologic modalities by ensuring that patient preferences are discussed and, at a minimum, providing some nonpharmacologic treatment options relevant to their patient population.” The requirement specifically lists acupuncture therapy as a suggested physical modality.

9 Continued: “The technical advisory panel for The Joint Commission’s pain standards review project recommended that organizations have readily available educational resources that staff and licensed independent practitioners can use to review pain assessment and pain management principles based on their specific specialty or even a specific clinical situation that they may encounter.”

10 Continued: “Access to pain specialists by consultation or referral reflects best practice in addressing patients with complex pain management needs.”

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“Provision of Care, Treatment, and Services (PC) 01.02.07:” Provision of Care, Treatment, and Services: The hospital assesses and manages the patient’s pain and minimizes the risks associated with treatment.

• “EP 3:” The hospital treats the patient’s pain or refers the patient for treatment. Treatment strategies for pain may include nonpharmacologic, pharmacologic, or a combination of approaches.

• “EP 4:” The hospital develops a pain treatment plan based on evidence-based practices and the patient’s clinical condition, past medical history, and pain management goals.

• “EP 5:” The hospital involves patients in the pain management treatment planning process through the following: … providing education on pain management, treatment options, and safe use of opioid and nonopioid medications when prescribed.”

The Healthcare Leadership CouncilThe Healthcare Leadership Council (HLC) is a coalition of chief executives representing all areas of the health care industry.

In June 2018, the HLC released a set of recommendations for addressing the opioid crisis, entitled “A Roadmap for Action.” Developed through the HLC’s National Dialogue for Healthcare Innovation initiative, the Opioid Roadmap included a wide swath of recommendations specifically addressing non-opioid, non-pharmacological treatments for pain.11

Recommendations for Lawmakers:• 4. Support research, funding, and expanded access to

innovative and evidence-based therapies, technologies, and approaches for integrated pain management as well as SUD treatment.

• 5. Work with healthcare stakeholders to build a base of evidence to support non-opioid, opioid-sparing, and non-pharmacologic treatments for pain and direct Medicare to reimburse for therapies that are shown to manage chronic and acute pain while minimizing the risk of opioid addiction.

Recommendations for Regulators:• 3. CMS should review and modify all reimbursement

policies to ensure that they do not create barriers for multi-modal pain treatment (including non-opioid, opioid-sparing, and non-pharmacologic therapies), as well as evidence-based SUD treatment.

• 5. Federal agencies, such as the CDC, CMS, and the FDA, should promote clinician and patient education and awareness of appropriate and evidence-based pharmacologic and non-pharmacologic pain management therapies through guidance to providers.

• 6. CMS should expand upon its existing Opioid Misuse Strategy to develop and leverage existing models for value-based payment for integrated pain management and comprehensive SUD treatment that incentivize evidence-based practices and quality care.

Acupuncture: An Effective, Proven Modality for Pain and Addiction TreatmentAt its heart, the opioid crisis is a crisis of pain management in the U.S. Clearly, there is a need for the proliferation of effective, nonpharmacological pain management treatments to reduce the incidence of opioid prescriptions and help alleviate the struggles of chronic pain patients. Acupuncture

11 “Opioid Crisis Solutions Summit: A Roadmap for Action,” National Dialogue for Healthcare Innovation, Healthcare Leadership Council. June 20, 2018.

One meta-analysis of almost 18,000 patients across 29 randomized controlled trials found that true acupuncture was significantly more effective than the absence of the service or sham acupuncture (placebo) controls.

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treatment is an evidence-based, cost-effective, and widely available modality for treating a wide variety of pain issues. The practice of safe acupuncture should be at the forefront of discussions for addressing the opioid crisis, as it has the potential to replace initial opioid prescriptions and to reduce the need for continuing opioid use for chronic and acute pain. In fact, evidence suggests that acupuncture can even be effectively utilized to combat symptoms of drug withdrawal. As federal agencies and state and local governments examine ways to address the opioid crisis, they should focus on expanding the use of acupuncture treatment as a widely-used, powerful, and safe modality for pain management, when performed by qualified, certified acupuncturists.

Acupuncture as Effective Pain ManagementThough acupuncture treatment can be used to treat a host of symptoms ranging from respiratory and neurological disorders to physical manifestations of tension and stress, perhaps the most vital use of acupuncture is pain control. As opioid prescriptions have risen and insurance companies have focused their reimbursement policies on cheap, generic drugs, holistic and integrative pain management plans have become less and less common. Comprehensive pain clinics, which were once considered the gold standard for treating chronic pain, closed in droves, or received drastic funding cuts. However, in settings where non-drug pain management is still a priority, acupuncture is often considered the “go-to” integrative therapy, as it is minimally invasive, creates only mild burden on the patient, and most of all, is extremely effective.

Acupuncture has been shown to be effective for treating numerous types of pain, especially chronic pain. Specifically, the strongest evidence has emerged for back pain, neck pain, shoulder pain, chronic headaches, and osteoarthritis. One meta-analysis of almost 18,000 patients across 29 randomized controlled trials found that true acupuncture was significantly more effective than the absence of the service or sham acupuncture (placebo) controls.12 More specifically, the Acupuncture

Evidence Project has tabulated research studies that have found evidence of positive or potential positive effects of acupuncture on different conditions, covering 46 different symptoms.13 Major practitioner groups have begun to realize the potential of acupuncture as a pain management modality, and in 2017, the American College of Physicians (ACP) published guidelines strongly recommending acupuncture as an effective treatment for chronic and acute lower back pain, a condition which often leads to opioid prescriptions among sufferers.14 The ACP also promotes payment reforms by public and private insurers to cover these services.

Acupuncture as Opioid Reduction or ReplacementAcupuncture can be used in place of an initial opioid prescription when faced with acute or chronic pain concerns. In fact, beyond simply treating pain, the mechanisms of acupuncture actually produce and release endogenous opioids in the body, acting as a natural analgesic without prescribing opioid drugs.15 Additionally, acupuncture activates opioid receptors in the brain, which would likely allow lower doses of opioid medication to be more effective when used together with acupuncture treatments.

12 Vickers AJ, Cronin AM, Maschino AC, Lewith G, MacPherson H, Foster NE, et al. Acupuncture for Chronic Pain: Individual Patient Data Meta-Analysis. Archives of Internal Medicine. 2012; 172(9): 1444-53.

13 McDonald J, Janz S. The Acupuncture Evidence Project: A Comprehensive Literature Review. Australian Acupuncture & Chinese Medicine Association Ltd, Dec. 19, 2016.14 Qaseem A, Wilt TJ, McLean RM, Forciea MA; Clinical Guidelines Committee of the American College of Physicians. Noninvasive Treatments for Acute, Subacute, and

Chronic Low Back Pain: A Clinical Practice Guideline from the American College of Physicians. Annals of Internal Medicine, 2017 April 4; 1667(7): 514-530.15 Zhang, R, Lao L, Ren K, Berman BM. Mechanisms of Acupuncture-Electroacupuncture on Persistent Pain. Anesthesiology, 2014; 120(2): 482-503.

Acupuncture activates opioid receptors in the brain, which would likely allow lower doses of opioid medication to be more effective when used together with acupuncture treatments.

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Acupuncture can therefore provide the same analgesic effects of opioid medications without the harmful potential for abuse or addiction. Significantly, studies on acupuncture as an opioid complement can result in reduced consumption of opioid-like medications (OLM) by more than 60% in post-surgical environments.16, 17

Acupuncture for Addiction Treatment and RehabilitationBeyond replacing or reducing opioid prescriptions for chronic and acute pain, acupuncture can actually be used to address symptoms post-addiction or abuse. Acupuncture for addiction has a broad evidence base showing that treatment can reduce or alleviate opioid withdrawal symptoms.18 The National Acupuncture Detoxification Association catalogs more than 1,000 programs across the United States and Canada that use acupuncture as a treatment modality for overcoming addiction, and as the number of opioid addicts in the U.S. continues to rise, acupuncture can and should be more widely used as a way to achieve drug independence.19

Acupuncture-Centered Solutions for Addressing the Opioid CrisisAs a safe, evidence-based, effective, and most importantly, nonpharmacological treatment for pain management, acupuncture needs to be at the forefront of the efforts to combat the opioid crisis in America. Three main actions can move towards this goal.

• As federal, state, and local governments work to promulgate education, best practices, and recommendations for healthcare providers around opioid prescriptions and pain treatments, acupuncture should be emphasized and endorsed as a proven method to decrease and even replace opioid doses and OLMs.

• The evidence base around acupuncture’s effectiveness needs to be expanded, and should be a focus on the increasing resources being spent on research.

Acupuncture has the potential to become a front-line treatment for dealing with chronic and acute pain, and can significantly reduce the incidence and levels of opioid prescriptions.

• The federal government should place a priority on fixing the reimbursement issues with CMS that incentivize physicians and hospitals to rely on opioid drugs over less dangerous nonpharmacological treatments for pain.

Increasing Acupuncture AwarenessAcupuncture has the potential to become a front-line treatment for dealing with chronic and acute pain, and can significantly reduce the incidence and levels of opioid prescriptions. Almost every group that has given recommendations on addressing the opioid crisis has placed a premium on identifying, developing, and promulgating non-opioid treatments for pain, and specifically improving patient access to such treatments. To that end, the most significant step that federal and state governments should take is increasing the awareness around acupuncture treatment among healthcare providers as a substitute for or complement to opioid prescriptions.

The President’s Commission recommended that “HHS coordinate the development of a national curriculum and standard of care for opioid prescribers.”20 The guideline was described as an update and supplement to the primary care-focused guidelines released by the CDC in 2016. In the CDC’s guidelines,

16 Lin JG, Lo MW, Wen YR, Hsieh CL, Tsai SK, Sun WZ. The Effect of High and Low Frequency Electroacupuncture in Pain after Lower Abdominal Surgery. Pain17 Wang B, Tang J, White PF, Naruse R, Sloninsky A, Kariger R, et al. Effect of the Intensity of Transcutaneous Acupoint Electrical Stimulation on the Postoperative Analgesic

Requirement. Anesthesia and Analgesia, 1997; 85(2): 406-13.18 Wen H, Cheung SYC. Treatment of Drug Addiction by Acupuncture and Electrical Stimulation. Asian Journal of Medicine, 1973; 9:139-141.19 National Acupuncture Detoxification Association. “About NADA.”20 “Final Report.”

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there is a moderate focus on determining when to initiate or continue opioids for chronic pain, which makes reference to nonpharmacologic therapy. Any guidelines developed by the Health Department, or any other federal agency, as well as updates to existing guidelines, should include information on such therapies and guidelines for how to refer to those therapies instead of prescribing opioids as a primary option. Specifically, since the evidence supports the effectiveness of acupuncture for many of the exact problems that opioids aim to address, a focus should be made on recommending or simply educating on the availability and use of acupuncture treatments.

As supplements to their 2016 guidelines, the CDC also publishes a series of educational modules and webinars to aid providers in applying the guidelines. These modules, which are eligible for continuing education (CE) credits for providers, should include information on nonpharmacological treatments like acupuncture, and can be an essential tool in educating providers on the options that are available to them and their patients beyond opioid drugs.

treatments for opioid overdoses – certainly worthwhile pursuits. However, for meaningful change, mitigating the risks of the opioid crisis must be paired with significant efforts to address the root causes of the problem – namely, the staggering amount of opioid prescriptions. To do so, the federal government must focus on developing a hearty body of evidence around alternative pain management treatments, with an emphasis on nonpharmacological options. HHS and its sub-agencies, specifically the ONDCP, the CDC, and the VA, should work to identify and fund research projects into the uses of acupuncture for chronic and acute pain. Reproducing the promising results of the many studies cited above would be a good start, and testing the effects of acupuncture on an even wider range of symptoms would allow healthcare providers to understand exactly how effective a treatment it can be.

Finally, the use of acupuncture in dealing with specific episodes of care, such as those involving high prescription rates for perioperative and postoperative acute pain, is ripe for study under the CMS. Specifically, the particular

The use of acupuncture in dealing with specific episodes of care, such as those involving high prescription rates for perioperative and postoperative acute pain, is ripe for study under the CMS.

Prioritizing Acupuncture ResearchWhile the existing evidence base surrounding acupuncture for chronic and acute pain concludes that acupuncture can be effective or very effective for a wide variety of symptoms, more research is needed, especially since the lack of peer-reviewed, well-understood research contributed to the rise of opioids as a prescriber tool. The President’s Commission also identified this as a necessary goal in their report. Specifically, the Commission called on federal agencies to review existing research programs and establish goals for continuing research.

Many of these agencies, especially the FDA, will likely focus on non-opioid analgesics, or developing more effective

authority granted to the Center for Medicare and Medicaid Innovation (CMMI) would allow for the development of a demonstration model to track and quantify the effects of acupuncture for such pain. There is a need for more data on the effects of acupuncture for pain in clinical settings, and a CMMI demonstration would provide a useful opportunity to test both the clinical outcomes and cost-effectiveness of acupuncture treatment compared to opioid prescriptions and other pain management options. This would allow for replication and expansion of the promising outcomes seen by state-based pilots, such as those in Vermont’s Medicaid program in 2017.

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Improving Reimbursement for Acupuncture & Other Non-Opioid TreatmentsThe President’s Commission specifically identified issues with CMS’ rate-setting policies as a driver of high opioid prescription rates. In the current system, bundled payments can make alternative treatment options cost-prohibitive for hospitals and physicians, especially when considering post-surgical acute pain. When hospitals participate in bundled payments for surgical procedures, the facility is reimbursed a single dollar amount for the entire episode of care. As the Commission report states, “any costs the hospital incurs for creating and administering a multimodal pain management strategy essentially get deducted from its fixed fee payment… inadequate reimbursement significantly hampers providers’ ability to utilize non-opioid treatment for postsurgical pain.”20

Similar issues exist with payers besides CMS as well. Overall, though research suggests that multimodal approaches, especially combining nonpharmacological treatments like acupuncture with smaller opioid prescriptions, can be significantly more effective than opioid-only treatments, reimbursement systems continue to incentivize prescribing cheap, generic drugs. In keeping with the

broad recommendations of nonpharmacological treatments, CMS should work with hospitals and practitioners to revise rate-setting policies to disincentivize opioid prescription and encourage wider use of alternative pain management therapies, especially acupuncture.

Currently, very few state Medicaid payers offer reimbursement for acupuncture treatment, despite the broad evidence base for effectiveness as pain management. Ohio, one of the states hardest hit by the opioid epidemic, made headway recently by beginning to cover acupuncture for the treatment of low back pain and migraines in 2017. The Ohio Medicaid program further broadened its rules effective Jan. 1, 2018 and allows independent acupuncturists to register as Medicaid providers and perform their services for Medicaid patients.21 The move towards covering acupuncture began as a response to Ohio Governor John Kasich’s Cabinet Opiate Action Team guidelines that recommended non-opioid pain treatment whenever possible. Other states should follow Ohio’s (as well as Oregon and Vermont’s, both states that have added or expanded Medicaid coverage for acupuncture in response to the opioid crisis) and explore avenues for covering and reimbursing acupuncture services through Medicaid.22, 23

1000+The number of programs that The National Acupuncture Detoxification Association has cataloged across the United States and Canada that use acupuncture as a treatment modality for overcoming addiction, and as the number of opioid addicts in the U.S. continues to rise, acupuncture can and should be more widely used as a way to achieve drug independence.

21 “Medicaid Transmittal Letter No. 3334-18-01.” January 1, 2018. Ohio Department of Medicaid.22 Gobeille, Al and Cory Gustafson. “Medicaid Acupuncture Pilot Project Outcomes Report.” September 29, 2017. Department of Vermont Health Access.23 Rickards, James, Kim Wentz, and Trevor Douglass. “OHP Fee-for-Service Coverage of Back and Spine Pain Diagnosis and Treatment.” March 6, 2017.

Oregon Health Authority.

VETERANS HEALTH ADMINISTRATION www.nccaom.org

BackgroundThe nationwide opioid crisis has blanketed the country, and the veteran population is one of the hardest-hit by chronic and acute pain. In 2013, more than 2 million veterans suffered from a chronic pain diagnosis, and the number is only growing. More than 50% of older veterans experience chronic pain, and that proportion jumps to 60% for veterans who served in the Middle East. Up to 75% of female veterans suffer from chronic pain. America’s veterans (along with active duty military) are facing high levels of pain, and widespread overreliance on opioid prescriptions only serves to exacerbate these issues. Fortunately, the Veterans Health Administration has worked to expand the availability of complementary and integrative health (CIH) treatments for veterans, including acupuncture for chronic pain.

Acupuncturist Job ClassificationIn February 2018, the Veterans Health Administration created a qualification standard for acupuncturists to become employed practitioners at the VA. Previously, the VA could only hire acupuncturists as contractors, and the agency had only recognized acupuncture as a treatment modality and not a profession. The standard sets the base requirements for an acupuncturist to be appointed as a VA practitioner, including education (Master’s degree or Master’s level program), licensure (active and unrestricted), and citizenship (U.S.). Most importantly, the VA requires NCCAOM Board-Certification as an essential part of ensuring safe and high-quality acupuncture treatment. The VA requires its acupuncturists to maintain a current NCCAOM certification and engage in continuing

education as mandated by NCCAOM. This classification will allow the thousands of veterans who suffer from chronic and acute pain to be treated by the most experienced and qualified acupuncturists, expanding access to treatment while protecting patient safety both at VA hospitals and throughout their outpatient referral networks.

VHA Work on Integrative CareThe VHA, as well as the Department of Defense, has been exploring and utilizing acupuncture and integrative care for years. The VHA has specifically worked to employ the Whole Health model, which approaches the veteran as a person instead of a problem and focuses on what matters most to the patient. By 2015, 93% of VHA facilities offered CIH services, with a focus on acupuncture and several other treatments with the best evidence of effectiveness. In 2009, the Army Pain Management Task Force was created to explore evidence-based complementary and alternative therapeutic modalities, including acupuncture, and this work has informed the VHA’s provision of care in the years since. The VHA developed 19 demonstration sites nationwide in 2018 to serve as centers for whole health approaches for the veteran population, and the agency continues to expand acupuncture treatment across its sites. Other initiatives include the Acupuncture Training Across Clinical Settings (ATACS) program, which has significantly expanded availability of acupuncture for veterans. In the coming months, the VHA will also be launching a study focused on the implementation and effectiveness of Battlefield Acupuncture (BFA), a technique which has already been met with positive feedback from veterans and seen more than 1000 providers trained under ATACS.

Acupuncture & Integrative Health at the Veterans Health Administration

93% The percentage of VHA facilities that offered Complementary and Integrative Health (CIH) services, with a focus on acupuncture and several other treatments with the best evidence of effectiveness by 2015.