PAIN+ CPN

Beltaief K, Grissa MH, Msolli MA, et al. Acupuncture versus titrated morphine in acute renal colic: a randomized controlled trial. J Pain Res. 2018 Feb 13;11:335-341. doi: 10.2147/JPR.S136299. eCollection 2018.
Ratings
Discipline Area Score
Physician 5 / 7
Abstract

Objective: The objective of this study was to compare the analgesic effect and tolerance profile of acupuncture versus intravenous (IV) titrated morphine in patients presenting to the emergency department (ED) with renal colic.

Materials and methods: A total of 115 patients were randomized into two groups. Patients in the IV titrated-morphine group (n=61) received 0.1 mg/kg morphine every 5 minutes until pain score dropped by at least 50% of its baseline value. Patients in the acupuncture group (n=54) received an acupuncture session of 30 minutes following a prespecified protocol. The visual analog scale (VAS) was used to assess pain intensity at baseline and at 10, 20, 30, 45, and 60 minutes following the start of the treatment protocol. Possible treatment side effects were also recorded.

Results: No significant differences were found between the two groups concerning age, sex, or baseline VAS score. From the 10th minute until the end of the intervention, acupuncture was associated with a deeper analgesic effect than titrated morphine (P<0.05 from the 10th minute and over). Analgesia was also faster in the acupuncture group, with time to obtain 50% reduction of baseline VAS of 14 minutes in the acupuncture group versus 28 minutes in the IV titrated-morphine group (P<0.001). Only three patients in the acupuncture group experienced minor side effects versus 42 in the morphine group (P<0.001). No major side effects were observed in this study.

Conclusion: In ED patients with renal colic, acupuncture was associated with a much faster and deeper analgesic effect and a better tolerance profile in comparison with titrated IV morphine.

Comments from MORE raters

Physician rater

A very small trial with short follow-up and no accounting for placebo effect.

Physician rater

This is a very small trial of an atypical intervention for the ED, and outcomes were analysed using questionable statistical methods.

Physician rater

An unblinded study of a speculative intervention that would not be accessible or affordable in most settings. Selective outcome reporting too.

Physician rater

This study adds to a growing body of literature demonstrating the viability of alternatives to opiates in the setting of severe acute pain. Although many EDs will not have the availability of acupuncture due to the need for expertise and dedicated resources, the study has general significance due to the importance of the aforementioned consideration.

Physician rater

Providers are actively seeking opioid alternatives as regulatory consequences of the 21st century opioid epidemic continue to unfold. Acupuncture is theoretically one such alternative, although critics frequently decry pseudoscience and strawman comparators. This RCT focuses on the common scenario of suspected renal colic and compares "licensed physician" acupuncture with 0.1 mg/kg IV morphine every 5 minutes - a reasonable comparator. They report a mean morphine dose of 16.7 mg (which equates to 2-3 doses for a 70 kg individual) and no difference in overall pain relief in the acupuncture group. Certainly worthy of attention with the caveat of uncertain external validity (single Tunisian ED - in other settings patient/clinician faith in acupuncture less likely and access to trained acupuncturist in ED unlikely) or internal validity with renal colic diagnosed without labs or imaging.

Physician rater

This is a small clinical trial with no sample size calculation and high risk of bias. It also has extraordinary results that are really hard to find in clinical practice, so they might be explained by random error or other explanation. An intervention controlled with sham acupuncture is a best design for this type of research.

Physician rater

Given the increase in opioid addiction and search for alternative methods of analgesia, this study offers the possibility of using acupuncture in place of narcotics. Further research is needed in other populations before this could be suggested as a widespread practice.

Physician rater

This study comparing acupuncture to intravenous morphine has design issues. The participants were not blinded, so it is clear who received acupuncture. Furthermore, morphine is slow on onset and the dose was repeated every 5 minutes. It would have been interesting to see the results if fentanyl were chosen.
Comments from PAIN+ CPN subscribers

No subscriber has commented on this article yet.