Title: Acupuncture for chronic pain and depression in primary care
Funder: Department of Health (England)

Abstract: Aims and objectives The overall aim of this programme is to establish rigorous evidence on the clinical and cost effectiveness of acupuncture for chronic pain and depression in primary care. Our objectives are: to conduct four meta-analyses of acupuncture using individual patient data (for low back pain, neck pain, headache and osteoarthritis of the knee); to conduct related economic evaluations with decision-analysis; to study ways to control for placebo effects, and to conduct a large randomised controlled trial to evaluate the effectiveness and cost-effectiveness of acupuncture for depression. Background Chronic pain represents a large burden to patients and the NHS. Patient demand for acupuncture is rising but there is uncertainty about the evidence. Evidence syntheses are needed where substantial recent evidence is now available. Comprehensive economic modelling is required for NHS decision-making. New robust RCTs are needed for chronic illnesses in primary care where the evidence from existing reviews and pilot RCTs is encouraging. Research Plans Project 1: Evidence synthesis: four individual patient data meta-analyses. A number of large, high quality trials of the clinical effectiveness of acupuncture for low back pain, neck pain, osteoarthritis of the knee, and headache have recently been published. We will incorporate these in individual patient meta-analyses comparing acupuncture to both usual care and to sham acupuncture. Project 2: Economic evaluation: modelling and decision analysis. We will conduct three economic evaluations with decision-analysis of acupuncture for low back pain, neck pain and headache when provided as an adjunct to usual care using data from Project 1. Then, as an exemplar, we will use a decision analytic modelling framework to synthesise the evidence for all common treatments, including acupuncture, for osteoarthritis of the knee. Project 3: Controlling for placebo effects in randomised controlled trials of acupuncture. Several recent trials of acupuncture have used a sham acupuncture intervention as a control. In these trials, acupuncture has been found to be equivalent to, or marginally better than real acupuncture. Because the mechanism of acupuncture is unknown, the role of the sham needle is unclear and therefore the results of these trials are difficult to interpret. In this project, we will explore a variety of sham interventions, and evaluate their adequacy. Project 4: Acupuncture for depression: an RCT. Systematic reviews suggest there is sufficient evidence on the effects of acupuncture to warrant further research. Building on our 40 patient pilot RCT of acupuncture vs. counselling vs. usual GP care alone, we will conduct a full scale RCT to determine clinical and cost effectiveness of acupuncture compared to usual care alone. We will also compare acupuncture to counselling, an intervention that will provide a control for equivalent time with an empathetic therapist. Research Team The research team will be led by dr MacPherson, a holder of a NIHR Career Scientist Award to evaluate the effectiveness of acupuncture. There is NHS involvement from a Clinical Services Manager (Wheeler), York Hospital Pain Clinic (Hall), and GPs (Geddes, Watt). The team includes specialists in acupuncture (Hall, Geddes, MacPherson), chronic pain (Hall, Morley), and mental health (Geddes, Gilbody, Morley) as well as experts in systematic reviews (Gilbody, Stewart, Woolacott), individual patient data meta-analyses (Stewart, Sutton), trials in primary care (Bland, Gilbody, Morley, Torgerson, Watt), and economic evaluation, modelling and decision analysis (Sculpher, Torgerson). Research Environment The University of York has a strong research health services research and clinical evaluation environment with key academic centres supporting the proposed programme: Department of Health Sciences, Centre for Reviews & Dissemination, Centre for Health Economics and York Trials Unit. Anticipated outputs The anticipated output of the programme will be a reduction in the clinical and economic uncertainties associated with the use of acupuncture in the management of chronic pain and depression, which are a burden in primary care. The proposed research will provide valuable evidence on effectiveness, costs and cost-effectiveness for patients, providers and decision-makers in order that they can make informed choices about referral and NHS commissioning. Public involvement We have had patient input into the design of the proposed trials and the writing of this grant application. There will be public involvement in the design, management and dissemination of the proposed research, including feedback on outcomes measures and documentation, membership of Trial Steering Committees, and an active role in the interpretation and dissemination of the results.


Research activity codes: 6.8 COMPLEMENTARY
Health categories: MUSCULOSKELETAL;MENTAL HEALTH;NEUROLOGICAL