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When is the evidence
enough to change the guidance?
Inside NICE's 2021 decision to recommend acupuncture for chronic pain.
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Fig. — NICE NG193 evidence threshold, stylised
01 / 06
For years, acupuncture's evidence for chronic pain was judged one trial at a time, one guideline at a time — a fragmented picture, with no single verdict.
STAGE 01 — A FRAGMENTED PICTURE
The strongest single body of evidence is the Acupuncture Trialists' CollaborationGlossaryAn international research group that pools raw patient data from many acupuncture trials to analyse them together, rather than relying on each trial's own published summary.'s individual patient data meta-analysisGlossaryA type of study that combines the actual patient-level records from many trials into one large analysis — more rigorous than pooling each trial's summary results. — real, patient-level records pooled from dozens of trials, updated in 2018 to just under 18,000 patients.
STAGE 02 — THE EVIDENCE BASE
NICE guideline committees use a pre-set bar to decide whether an effect counts as meaningful, not just statistically real: a standardised mean differenceGlossaryA way of measuring how large a treatment's effect is, expressed in a standard unit so results from different studies can be fairly compared. of 0.5 or greater — the minimal clinically important differenceGlossaryOften shortened to MCID — the smallest improvement in a treatment that a patient would actually notice or care about, as opposed to a change that's only detectable statistically..
STAGE 03 — THE BAR FOR "MEANINGFUL"
In April 2021, the committee assessing chronic primary painGlossaryPersistent pain — such as fibromyalgia or myofascial pain — that isn't fully explained by a separate, identifiable condition. — pain such as fibromyalgia, myofascial pain, chronic pelvic pain and neck pain, without a separate condition fully explaining it — found acupuncture's effect size cleared that bar.
STAGE 04 — CLEARING THE THRESHOLD
The result was NICE guideline NG193GlossaryThe reference code for NICE's 2021 guideline on chronic pain — each NICE guideline is identified by a code like this.: a recommendation to consider a single course of acupuncture for chronic primary pain — the first time acupuncture had passed this specific, pre-defined evidentiary test in NICE guidance.
STAGE 05 — THE RECOMMENDATION
The same guideline also recommended against several medicines still widely used for chronic pain — including opioidsGlossaryStrong painkillers derived from or similar to morphine (e.g. codeine, tramadol, oxycodone) — effective for acute pain, but carrying a real risk of dependence with long-term use., NSAIDsGlossaryNon-Steroidal Anti-Inflammatory Drugs — common over-the-counter and prescription painkillers like ibuprofen and naproxen that reduce pain and inflammation. and paracetamolGlossaryOne of the most widely used over-the-counter painkillers (known as acetaminophen in the US) — generally well tolerated, but with limited effect on chronic pain specifically. — for this type of pain specifically. That part of the story is told far less often.
STAGE 06 — THE FULL PICTURE
A recommendation
with a real bar behind it
NICE's guidance on chronic primary pain sits behind a specific, pre-defined evidentiary threshold — not a general endorsement, and not for every type of pain. Within that guidance, a single course of acupuncture is a genuine, evidence-backed option.
Sources: Cummings M. "Integration of Acupuncture into UK Healthcare — A NICE Perspective." Perspectives on Integrative Medicine, 2023;2(1):3–7 (the author is affiliated with the British Medical Acupuncture Society, an acupuncture advocacy body — this piece presents his account of the guideline history, not an independent audit). NICE guideline NG193, "Chronic pain (primary and secondary) in over 16s," published April 2021. Vickers AJ, Vertosick EA, et al. "Acupuncture for Chronic Pain: Update of an Individual Patient Data Meta-Analysis." J Pain, 2018;19(5):455–474. This piece deliberately covers NG193 (chronic primary pain) only — NICE's separate guidance on back pain and osteoarthritis follows a different evidence path and is not addressed here. Provided for context, not as a clinical guarantee; acupuncture at Zen by Omnia is offered as a complementary therapy alongside, not in place of, medical care.
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