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• Please Review and Revise to Include the Acupuncture Results
  John S. Misa
  Published on: 6 November 2019
• Note from the Editors
  Edward Sucksmith
  Published on: 6 November 2019
• Important Omission of Acupuncture in the Abstract Does Not Reflect Results
  Richard Harris, Mark Bovey, David W. Miller and Freda Dreher
  Published on: 29 October 2019
• Acupuncture left out of conclusion.
  Larissa Vados
  Published on: 25 October 2019
• Remarkable Study. Why did you " exclude,"acupuncture/acupuncturist" in your conclusions and results?
  Michael Egan
  Published on: 16 October 2019

• Published on: 6 November 2019

  Please Review and Revise to Include the Acupuncture Results

  • John S. Misa, Vice President, Medical Operations Allina Health

  To the editors of the BMJ:

  Allina Health is a Minnesota based not-for-profit healthcare system caring for patients across our 90+ clinics, 12 hospitals, 15 pharmacies, specialty care centers and specialty medical services. This includes our Penny George Institute for Health and Healing, which brings together physical therapy, chiropractic care and acupuncture alongside our traditional healthcare system to provide whole-person-care. As one of the largest healthcare systems in the United States, we are deeply committed to making a positive difference in the opioid crisis by including access to all effective modalities of care.

  We found your recently published paper (by Kazis et al [BMJ Open 2019;9e028633] regarding their retrospective study of the association between initial health provider for low back pain with subsequent opioid use) to be a very valuable study with the potential to further shape healthcare’s response to the opioid epidemic. Unfortunately, some of the pertinent concluding evidence has been left out of the abstract - specifically acupuncture effectiveness. We are reaching out to request that you address this in order to maximize the acceptance of all effective treatments in responding to our opioid crisis.

  In the body of the study, data on three types of conservative therapists as well as various types of physicians are included. It showed that there was a decrease in both early and long-term opioid use among patients with either physi...

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  To the editors of the BMJ:

  Allina Health is a Minnesota based not-for-profit healthcare system caring for patients across our 90+ clinics, 12 hospitals, 15 pharmacies, specialty care centers and specialty medical services. This includes our Penny George Institute for Health and Healing, which brings together physical therapy, chiropractic care and acupuncture alongside our traditional healthcare system to provide whole-person-care. As one of the largest healthcare systems in the United States, we are deeply committed to making a positive difference in the opioid crisis by including access to all effective modalities of care.

  We found your recently published paper (by Kazis et al [BMJ Open 2019;9e028633] regarding their retrospective study of the association between initial health provider for low back pain with subsequent opioid use) to be a very valuable study with the potential to further shape healthcare’s response to the opioid epidemic. Unfortunately, some of the pertinent concluding evidence has been left out of the abstract - specifically acupuncture effectiveness. We are reaching out to request that you address this in order to maximize the acceptance of all effective treatments in responding to our opioid crisis.

  In the body of the study, data on three types of conservative therapists as well as various types of physicians are included. It showed that there was a decrease in both early and long-term opioid use among patients with either physical therapists (PTs), chiropractors or acupuncturists. While all three of these conservative therapies and results are discussed in the paper, only chiropractic and physical therapy results are mentioned in the abstract - the acupuncture results are missing.

  We are respectfully requesting that the abstract be reviewed and revised to include the acupuncture results. Exclusion of these results may diminish an effective alternative form of therapy we hope to leverage in addressing the opioid crisis.

  Thank you for your consideration,

  John S. Misa, MD
  Vice President, Medical Operations
  Allina Health

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  Conflict of Interest:
  None declared.

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• Published on: 6 November 2019

  Note from the Editors

  • Edward Sucksmith, Senior Assistant Editor BMJ

  The editors acknowledge the readers' comments about this article. We have asked the authors to respond and we will amend the article if necessary.

  Conflict of Interest:
  I am an Assistant Editor for BMJ Open.

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• Published on: 29 October 2019

  Important Omission of Acupuncture in the Abstract Does Not Reflect Results

  • Richard Harris, Associate Professor Department of Anesthesiology, University of Michigan
  • Other Contributors:
    • Mark Bovey, Acupuncture Provider
    • David W. Miller, Pediatrician and Acupuncture Provider
    • Freda Dreher, Physical Medicine / Rehabilitation

  Dear BMJ Open Editor Adrian Aldcroft,

  We read with interest the recent paper by Kazis et al [BMJ Open 2019;9e028633], an observational retrospective study of the association between initial health provider for low back pain with subsequent opioid use.

  This included data on three types of conservative therapists as well as various types of physicians. Initial treatment from any of the former, namely physical therapists (PTs), chiropractors and acupuncturists, was associated with substantially decreased odds for both early and long-term opioid use. However, these results, though tabulated, described and discussed in the main text of the paper do not transfer in the same form to the abstract. Specifically, the acupuncture results have been removed.

  The benefits of both PT and chiropractic are stated in two places in the Results section and once in the Conclusions, but there is no mention of acupuncture. Although we understand that the sample of acupuncturists was relatively small, acupuncture reduced short and long term exposure to opioids by 75% to 90% compared to the same patient starting with a PCP, and the confidence interval was significant and similar to PT.

  Given that many people will look initially or only at the abstract, this omission misleads the reader into inferring that acupuncture did not have the same benefits as the other two conservative treatments. The implications for health care policy/access/delivery are of concern. Does a...

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  Dear BMJ Open Editor Adrian Aldcroft,

  We read with interest the recent paper by Kazis et al [BMJ Open 2019;9e028633], an observational retrospective study of the association between initial health provider for low back pain with subsequent opioid use.

  This included data on three types of conservative therapists as well as various types of physicians. Initial treatment from any of the former, namely physical therapists (PTs), chiropractors and acupuncturists, was associated with substantially decreased odds for both early and long-term opioid use. However, these results, though tabulated, described and discussed in the main text of the paper do not transfer in the same form to the abstract. Specifically, the acupuncture results have been removed.

  The benefits of both PT and chiropractic are stated in two places in the Results section and once in the Conclusions, but there is no mention of acupuncture. Although we understand that the sample of acupuncturists was relatively small, acupuncture reduced short and long term exposure to opioids by 75% to 90% compared to the same patient starting with a PCP, and the confidence interval was significant and similar to PT.

  Given that many people will look initially or only at the abstract, this omission misleads the reader into inferring that acupuncture did not have the same benefits as the other two conservative treatments. The implications for health care policy/access/delivery are of concern. Does access to “conservative therapies” change one’s likelihood of using opioids? The answer is “yes.” Many patients don't want opioids or other analgesics, but they are not given reasonable access to “conservative therapies” due to issues of availability (we don't offer acupuncture, here) or cost (acupuncture is not covered by insurance so you must pay out of pocket and cannot afford it).

  We kindly ask that this omission be corrected.

  Richard Harris, PhD, LAc. Society for Acupuncture Research

  Mark Bovey, MSc. British Acupuncture Council

  David Mills, MD, LAc American Society of Acupuncturists

  Freda Dreher, MD American Academy of Medical Acupuncture

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  Conflict of Interest:
  None declared.

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• Published on: 25 October 2019

  Acupuncture left out of conclusion.

  • Larissa Vados, Licensed Acupuncturist M Health Fairview (My response is not affiliated with M Health Fairview)

  To Whom it May Concern:

  I am a licensed acupuncturist in the state of Minnesota, working with a large hospital system. I was looking forward to reading this important study when I heard about it, but I was disappointed and unclear why acupuncture is left out of the conclusion completely although it is included as a "conservative therapy" type.

  This study clearly shows acupuncture showed similar results to both chiropractic and PT, as stated in the body of the text: " For early opioid use, patients initially visiting chiropractors had 90% decreased odds (95% CI 0.09 to 0.10) while those visiting an acupuncturists had 91% decreased odds (95% CI 0.07 to 0.12) and those visiting physical therapists had 85% decreased odds (95% CI 0.13 to 0.17). Chiropractors, acupuncturists and physical therapists all had major decreased odds of long-term opioid use compared with those who initially saw PCPs ."

  As you can see, however, in the conclusion only chiropractic and PT are mentioned by name: "Results Short-term use of opioids was 22%. Patients who received initial treatment from chiropractors or physical therapists had decreased odds of short-term and long-term opioid use compared with those who received initial treatment from primary care physicians (PCPs) (adjusted OR (AOR) (95% CI) 0.10 (0.09 to 0.10) and 0.15 (0.13 to 0.17), respectively). Compared with PCP visits, initial chiropractic and physical therapy also were associated with dec...

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  To Whom it May Concern:

  I am a licensed acupuncturist in the state of Minnesota, working with a large hospital system. I was looking forward to reading this important study when I heard about it, but I was disappointed and unclear why acupuncture is left out of the conclusion completely although it is included as a "conservative therapy" type.

  This study clearly shows acupuncture showed similar results to both chiropractic and PT, as stated in the body of the text: " For early opioid use, patients initially visiting chiropractors had 90% decreased odds (95% CI 0.09 to 0.10) while those visiting an acupuncturists had 91% decreased odds (95% CI 0.07 to 0.12) and those visiting physical therapists had 85% decreased odds (95% CI 0.13 to 0.17). Chiropractors, acupuncturists and physical therapists all had major decreased odds of long-term opioid use compared with those who initially saw PCPs ."

  As you can see, however, in the conclusion only chiropractic and PT are mentioned by name: "Results Short-term use of opioids was 22%. Patients who received initial treatment from chiropractors or physical therapists had decreased odds of short-term and long-term opioid use compared with those who received initial treatment from primary care physicians (PCPs) (adjusted OR (AOR) (95% CI) 0.10 (0.09 to 0.10) and 0.15 (0.13 to 0.17), respectively). Compared with PCP visits, initial chiropractic and physical therapy also were associated with decreased odds of long-term opioid use in a propensity score matched sample (AOR (95% CI) 0.21 (0.16 to 0.27) and 0.29 (0.12 to 0.69), respectively).

  Conclusions Initial visits to chiropractors or physical therapists is associated with substantially decreased early and long-term use of opioids. Incentivising use of conservative therapists may be a strategy to reduce risks of early and long-term opioid use."

  This study provides some important information we can use to build on for future research, and to guide treatment plans for patients coming to the clinic or ED with low back pain. I am very interested to know why specific mention of acupuncture was left out of the conclusion, despite having similar results to both chiropractic and PT.

  I would appreciate your consideration to include acupuncture in your results and conclusion.

  Sincerely,

  Larissa Vados, PhD, L.Ac.

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  Conflict of Interest:
  None declared.

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• Published on: 16 October 2019

  Remarkable Study. Why did you " exclude,"acupuncture/acupuncturist" in your conclusions and results?

  • Michael Egan, Licensed Acupuncturist Allina Health (My response is not affiliated with Allina Health)

  To Whom it May Concern,

  Thank you so much for this incredible study and publication.

  As a licensed acupuncturist in the Minnesota, I am incredibly grateful for this amazing study.

  I saw this study presented at a conference last year and was so very looking forward to the publication.

  I was, however confused and disappointed why you only include, "chiropractor and physical therapist" in your conclusion and results?

  Your study clearly indicates that seeing an acupuncturists or getting acupuncture provides patients with choice and marked benefit: " For early opioid use, patients initially visiting chiropractors had 90% decreased odds (95% CI 0.09 to 0.10) while those visiting an acupuncturists had 91% decreased odds (95% CI 0.07 to 0.12) and those visiting physical therapists had 85% decreased odds (95% CI 0.13 to 0.17). Chiropractors, acupuncturists and physical therapists all had major decreased odds of long-term opioid use compared with those who initially saw PCPs ."

  Yet, in your results and conclusion you do not include the acupuncture profession:
  "Results Short-term use of opioids was 22%. Patients who received initial treatment from chiropractors or physical therapists had decreased odds of short-term and long-term opioid use compared with those who received initial treatment from primary care physicians (PCPs) (adjusted OR (AOR) (95% CI) 0.10 (0.09 to 0.10) and 0.15 (0.13 to 0.17), respectively)...

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  To Whom it May Concern,

  Thank you so much for this incredible study and publication.

  As a licensed acupuncturist in the Minnesota, I am incredibly grateful for this amazing study.

  I saw this study presented at a conference last year and was so very looking forward to the publication.

  I was, however confused and disappointed why you only include, "chiropractor and physical therapist" in your conclusion and results?

  Your study clearly indicates that seeing an acupuncturists or getting acupuncture provides patients with choice and marked benefit: " For early opioid use, patients initially visiting chiropractors had 90% decreased odds (95% CI 0.09 to 0.10) while those visiting an acupuncturists had 91% decreased odds (95% CI 0.07 to 0.12) and those visiting physical therapists had 85% decreased odds (95% CI 0.13 to 0.17). Chiropractors, acupuncturists and physical therapists all had major decreased odds of long-term opioid use compared with those who initially saw PCPs ."

  Yet, in your results and conclusion you do not include the acupuncture profession:
  "Results Short-term use of opioids was 22%. Patients who received initial treatment from chiropractors or physical therapists had decreased odds of short-term and long-term opioid use compared with those who received initial treatment from primary care physicians (PCPs) (adjusted OR (AOR) (95% CI) 0.10 (0.09 to 0.10) and 0.15 (0.13 to 0.17), respectively). Compared with PCP visits, initial chiropractic and physical therapy also were associated with decreased odds of long-term opioid use in a propensity score matched sample (AOR (95% CI) 0.21 (0.16 to 0.27) and 0.29 (0.12 to 0.69), respectively).

  Conclusions Initial visits to chiropractors or physical therapists is associated with substantially decreased early and long-term use of opioids. Incentivising use of conservative therapists may be a strategy to reduce risks of early and long-term opioid use."

  Can you please tell my why you excluded acupuncture/acupuncturist from your results and conclusion?

  I would so greatly appreciate it you would consider including the terms, "acupuncture or licensed acupuncturist" in your results and conclusions.

  Respectfully,
  Michael Egan, L.Ac, MaOM, DiplOM

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  Conflict of Interest:
  None declared.

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