The Regulation of the Practice of Acupuncture by Physicians in the United States

Abstract

Introduction: The landscape of acupuncture regulation has greatly evolved since the National Institutes of Health Consensus Statement in 1997. In recent decades, acupuncture treatment has become increasingly integrated with conventional medical care. Healthcare practitioners often utilize acupuncture as an adjunctive therapy to help alleviate symptoms of many conditions, such as nausea and pain. The popularity of this complementary and alternative modality has elevated the importance and urgency for states to regulate its practice and safety.

Materials and Methods: The authors comprehensively examined the regulation of the practice of acupuncture by licensed physicians in the United States. Current statutes were evaluated with respect to those from past decades. Requirements were compared with the World Health Organization's recommendations for acupuncture basic training and safety.

Results: Most physicians are permitted to practice acupuncture within the scope of their medical practices. Many states mandate that they complete additional education and training. Three states require that physicians obtain acupuncture licenses through the same process as non-physicians. Compared to prior decades, many states have changed their requirements.

Conclusions: This article provides current, individual state regulations for the practice of acupuncture by physicians.

Introduction

Physicians in the United States have been practicing acupuncture since it was first introduced to the country in the early 1800s.¹ Acupuncture gained a greater following during the twentieth century. James Reston's 1971 visit to China and documentation of his experience with acupuncture in The New York Times² revived interest in this ancient Chinese therapy.³ Since the 1997 National Institutes of Health Consensus Statement supporting acupuncture for managing nausea, vomiting, and postoperative pain,⁴ acupuncture has become incorporated increasingly into conventional medical practices in the United States. In a 2007 survey conducted by the Centers for Disease Control and Prevention's National Center for Health Statistics, almost 40% of adults used complementary and alternative therapies, such as acupuncture, in the prior year.⁵ The burgeoning popularity of acupuncture has necessitated the development of regulations and guidelines for acupuncture practitioners.

Regulation of acupuncture practice ensures that healthcare providers have the requisite knowledge for providing the therapies and serves as a safeguard to prevent potential adverse events in patients. Similar to the practice of medicine in the United States, the practice of acupuncture is determined by each state. For many states, the medical board governs licensed physicians who provide acupuncture. Other states have established acupuncture boards that provide physicians with requirements. In 1994, only 12 states developed requirements for physicians practicing acupuncture¹; most have done so by 2017.

The World Health Organization (WHO) recommends 200 hours of formal training for physicians who would like to incorporate acupuncture into their medical practices.⁶ It suggests further advanced personalized training for physicians desiring more expertise in the field.⁶ Physicians and dentists may also gain experience in specific fields, such as acupuncture for pain or dental analgesia, for further preparation in their particular medical specialties.⁶

The goal of our research was to provide a comprehensive investigation of current guidelines and analysis of modern regulations of acupuncture practice among physicians in the United States. Previous research conducted in 1999 outlined acupuncture regulation in the 50 states and the District of Columbia, but many regulations have since changed.⁷ This article presents an updated examination of the requirements for physicians to use acupuncture. The current regulations were compared with prior research. In addition, each state's legal regulations were examined with respect to the WHO's guidelines on basic training for acupuncture.

Materials and Methods

The primary objective of this research was to gain an understanding of whether or not acupuncture falls within the scope of practice for physicians in each state. The statutes and regulations in the United States were investigated for licensed physicians' current requirements to practice acupuncture. Each state has a medical board that promulgates regulations relating to licensing. Some states have also established acupuncture committees appointed by the medical board or acupuncture boards that regulate acupuncture practice. From 2016 to 2017, a comprehensive search of the state medical board information was performed, first identifying statutes and chapters relating to professions, medicine, acupuncture, and licensing. States' administrative codes were examined for regulations provided by the state agencies. If further information was required beyond examining state statutes, regulations, and guidelines or policies of the medical board or acupuncture board, the state medical boards and acupuncture regulatory boards were contacted. Once the laws were tabulated for each state, the regulations in the 1999 article⁷ were compared to the current ones. State statutes and regulations were evaluated with respect to the WHO guidelines for each state.

Many states allow physicians to administer acupuncture treatment under their medical licenses. For states that permit physicians to practice acupuncture within the scope of their medical practices if they complete additional training, the required hours of training were recorded. For some states, this training provided physicians with additional credentials, such as physician–acupuncturist licenses, acupuncture certifications, or acupuncture licenses, which were distinct from the process needed to obtain an acupuncture license for nonphysicians. For these cases, the additional hours of training as well as subsequent credentialing conferred were noted.

Some states only allowed physicians to provide acupuncture if they obtained acupuncture licenses through the same processes as nonphysicians. Finally, states that had no ruling and formalized requirements set forth by their medical or acupuncture boards were recorded as: “State regulatory agency has not provided a ruling.”

Results

Most licensed physicians in the United States are permitted to practice acupuncture within the scope of their medical practices (Tables 1 and 2). Three states, Hawaii, New Mexico, and Montana, require that physicians obtain acupuncture licenses through the same application process as nonphysicians who wish to practice acupuncture.

Table 1.

Regulation of Practice of Acupuncture by Physicians in the United States

States	Within scope of practice for physicians/comments
Alabama	Yes
Alaska	Yes
Arizona	Yes
Arkansas	State regulatory agency has not provided a ruling
California	Yes
Colorado	Yes
Connecticut	Yes
Delaware	Yes
DC	Yesa 250 hours
Florida	Yes
Georgia	Yesa 300 hours
Hawaii	No (must obtain acupuncture license)
Idaho	Yes
Illinois	Yes
Indiana	Yes
Iowa	Yes
Kansas	Yes
Kentucky	Yes
Louisiana	Yesa 6 months or 300 hours (to obtain certification as physician–acupuncturist)
Maine	Yes
Maryland	Yesa 200 hours
Massachusetts	Yes
Michigan	Yes
Minnesota	Yes
Mississippi	Yesa 200 hours
Missouri	Yes
Montana	No (must obtain acupuncture license)
Nebraska	Yes
Nevada	Yes
New Hampshire	Yes
New Jersey	Yesa 300 hours
New Mexico	No (must obtain acupuncture license)
New York	Yesa 200 hours of instruction and 100 hours of supervised experience (to obtain acupuncture certification)
North Carolina	Yes
North Dakota	Yes
Ohio	Yes
Oklahoma	State regulatory agency has not provided a ruling
Oregon	Yes
Pennsylvania	Yesa 200 hours (to obtain license from the Board as an acupuncturist)
Rhode Island	Yesa complete ABMA-approved training course for physicians
South Carolina	Yesa 300 hours
South Dakota	State regulatory agency has not provided a ruling
Tennessee	Yes
Texas	Yes
Utah	Yes
Vermont	Yes
Virginia	Yesa 200 hours of instruction, of which at least 50 hours must be clinical experience
Washington	Yes
West Virginia	Yes
Wisconsin	Yes
Wyoming	State regulatory agency has not provided a ruling

^aAdditional training is required.

DC, District of Columbia; ABMA, American Board of Medical Acupuncture.

Table 2.

Acupuncture Regulation Summary

Within scope of practice for physicians	States
Yes	AL, AK, AZ, CA, CO, CT, DE, FL, ID, IL, IN, IA, KS, KY, ME, MA, MI, MN, MO, NE, NV, NH, NC, ND, OH, OR, TN, TX, UT, VT, WA, WV, WI
Yes, with additional training	DC, GA, LA, MD, MS, NJ, NY, PA, RI, SC, VA
No	HI, MT, NM
State regulatory agency has not provided a ruling	AR, OK, SD, WY

DC, District of Columbia.

Many states require that physicians meet additional education and training requirements. For example, it is common to mandate that physicians successfully complete an acupuncture program approved by the state's medical board. Rhode Island specifically indicates that the American Board of Medical Acupuncture (ABMA) must approve the training program. The ABMA is affiliated with the American Academy of Medical Acupuncture, the professional society of medical physicians in North America that advocates and seeks to enhance the training and quality of medical practice among physicians incorporating acupuncture into conventional medicine. The organization maintains a list of approved acupuncture-training programs for physicians.

Some state regulatory agencies have not provided rulings or formalized requirements for physicians to practice acupuncture. For these states, the current authors contacted the individual medical boards and state acupuncture boards, if applicable. The medical boards responded that, while there are no requirements established by the medical boards, physicians must be adequately educated and trained to perform acupuncture safely and skillfully. Physicians must meet standards of care and not subject patients to unnecessary risk or harm. It is the physicians' responsibility to ensure that they are appropriately trained and competent to provide acupuncture as licensed physicians.

When comparing the current statues and regulations with the previous 1999 article on acupuncture regulation in the United States,⁷ it was found that some states have increased their requirements. For example, in 1999, Mississippi had no additional training required for physicians practicing acupuncture within the scope of their medical practices.⁷ Current regulations include 200 hours of American Medical Association or American Osteopathic Association approved Category I continuing medical education in acupuncture. Another state, Georgia, has expanded its additional training requirements from 100 hours in 1999⁷ to 300 hours.

The District of Columbia, Louisiana, Maryland, New Jersey, New York, Pennsylvania, and Virginia have the same hours of additional training in 1999 as in 2017.⁷ While acupuncture was not regulated in Idaho during 1999,⁷ this modality is now within the practice of medicine. In Arkansas, South Dakota, and Wyoming, acupuncture remains unregulated by the state regulatory agencies in 2017 as in 1999.⁷

A few states have decreased their requirements over the decades. For example, in 2017, Vermont considers acupuncture to be within the scope of practice for physicians, although the state did not permit this treatment ∼2 decades prior.⁷ Rhode Island also allows physicians to practice acupuncture under their licenses after successful completion of an ABMA-approved course, while, in 1999, this state did not allow physicians to do so.⁷

Regarding the WHO guidelines, 13 states and the District of Columbia fulfill the requirement of 200 hours of formal training in acupuncture for physicians. Of these states, 9 and the District of Columbia exceed the WHO requirements. Thus, most states' statutes and regulations do not reflect the minimum training and education recommendations promulgated by the WHO; however, many physicians have still sought experience that exceeds the minimum WHO recommendations. For example, even in states that do not specify particular training guidelines, physicians practicing acupuncture have pursued ABMA certification, a process exceeding the WHO suggestions. The ABMA maintains a Board-certification process for physicians utilizing acupuncture in their Western medical practices. This includes an application for Board certification, acupuncture education and training requirements, an acupuncture experience requirement, and a comprehensive written Board examination. The ABMA maintains a publically accessible list of these Board-certified physicians.

Discussion

Healthcare providers are increasingly recognizing that management of complex conditions, such as chronic pain, requires a multidisciplinary approach and that adjunctive acupuncture can be helpful for treating many of these conditions. Acupuncture, an ancient Chinese medical technique practiced for thousands of years, is safe to implement in adults^8,9 and children.¹⁰ It can be helpful for alleviating pain in many conditions, such as headache,^11,12 and for reducing the occurrence of postoperative nausea.¹³ A study on the use of acupuncture by U.S. physicians noted that common reasons for physicians to perform acupuncture include its efficacy, the lack of full recovery in many patients using standard medical approaches, and acupuncture's usefulness for pain management.¹ The growing utilization of acupuncture in conjunction with Western medicine has prompted regulation of acupuncture practice in the Western medical field. Updating the guidelines for acupuncture practice by physicians remains an ongoing task by the medical community, and changes in statutory regulation continue; for example, Vermont revised its laws relating to acupuncture practice by physicians in 2016, and Wyoming's first Acupuncture Practice Act takes into effect in 2018.

States' specific requirements vary widely. New York has established certification for physicians and dentists to use acupuncture. This process contrasts with acupuncture licensing for nonphysicians. Pennsylvania requires acupuncture licenses from the state board of medicine, which has different requirements for medical doctors compared to nonphysician applicants. Similarly, Louisiana regulates acupuncture certification, but there are different procedures for physician acupuncturists and acupuncturists' assistants. The former requires a current license issued by the board to practice medicine in the State of Louisiana, while the latter is open to nonphysicians who must practice acupuncture under the supervision of physicians. In contrast, physicians in Alabama may practice acupuncture without obtaining acupuncture licensure. In Alabama, chiropractors may do so when permitted by the state licensing board, the Alabama State Board of Chiropractic Examiners, after completing requisite training.

Some states make a distinction between solid needles and acupuncture. In Montana, physicians may use solid needles to perform procedures and therapeutic modalities; however, they may not refer to this practice as acupuncture. If they aim to practice acupuncture, they must hold additional licensure as acupuncturists. The procedure for physicians to obtain acupuncture licenses is very similar to that of nonphysicians, except that physicians do not need to take additional examinations in anatomy, physiology, chemistry, and related subjects that were required to obtain their medical licenses. Most places, unlike Montana, do not differentiate between the terminologies of acupuncture and solid needles.

While many requirements differ among states, a universal theme is the concern for safety: throughout the United States, physicians must practice with precautions to ensure the safety of their patients. For states that do not provide specific training regulations, physicians must have appropriate training and competency to offer safe treatment. The WHO recommends that all physicians who aim to practice adjunctive acupuncture treatment include a component on safety guidelines in acupuncture as part of their 200 hours of formal acupuncture training.⁶ Goals in guaranteeing that healthcare providers adhere to safety include ensuring that physicians select patients appropriately, recognize contraindications and complications, and respond effectively to potential medical emergencies.⁶ Knowledge and experience with the clean-needle technique and sterile needling are essential for any healthcare provider offering acupuncture treatment to avoid potential yet rare adverse events.

Future studies can analyze how different states' regulations have influenced the maximum training physicians seek. For example, the minimum requirements do not necessarily reflect physicians' actual training. Further research may also determine the proportion of physicians practicing acupuncture in the United States who are also licensed acupuncturists.

Additional investigation could explore whether variations in acupuncture training influence health outcomes and patient satisfaction. Previous work has suggested that the prior training of healthcare providers could affect the type of care provided; physicians often provide other medical treatments in addition to acupuncture treatment, while nonphysician licensed acupuncturists often utilize Traditional Chinese Medicine in addition to acupuncture.¹⁴ It is unknown whether these differences lead to variations in quality of medical care and health outcomes. Future research focusing on the outcomes of acupuncture treatment provided by U.S. physicians with varying levels of acupuncture training may provide understanding of whether type of acupuncture training affects quality of healthcare.

Compared to the United States, other countries have different laws for the practice of acupuncture. In the United Kingdom, there are no regulations regarding acupuncture training or the practice of acupuncture, although practitioners may be required to register with their local authorities. Additional research could examine whether the lack of regulations in the United Kingdom has engendered differences in style and quality of acupuncture treatment compared to the United States. Similar to the United States, Canada has different regulations for each province or territory. In Quebec, physicians must complete 300 hours of an acupuncture-training program approved by the credentials committee of the Collège des Médecins du Québec. Provinces such as Manitoba have no regulations for physicians.

The current study had limitations. As statutes and regulations change regularly, the guidelines outlined above for each state will likely evolve. This document, therefore, provides a comprehensive analysis of the state of regulation of acupuncture by physicians in the United States at one timepoint. It might be useful to conduct subsequent comparisons as states' laws continue to be amended in the future.

Conclusions

The regulation of the practice of acupuncture has never been more important. As more physicians incorporate acupuncture into their medical practices, updating the regulations on training and administration of acupuncture is paramount for ensuring that the care patients receive is safe, up-to-date, and effective. This article provides an overview of the current standards for licensed physicians in the United States who desire to practice acupuncture. Examination of the guidelines revealed many changes over the past decades. Each of the states has varying levels of regulations, and many conform to the WHO suggestions for acupuncture training and safety. Future studies can continue to monitor the progress of acupuncture regulation for physicians in America.

Author Disclosure Statement

No competing financial conflicts exist.

CME Quiz Questions

Article learning objectives:

After studying this article, participants should be able to summarize the history and current state of regulation of physician acupuncture in the United States; evaluate the requirements for physician acupuncture training in the United States; and examine and judge the current state of acupuncture regulation for physicians in the United States.

Publication date: June 7, 2017

Expiration date: June 30, 2018

Disclosure Information:

Authors have nothing to disclose.

Richard C. Niemtzow, MD, PhD, MPH, Editor‐in‐Chief, has nothing to disclose.

Questions:

• 1. Identify the incorrect statement:

  • a. The World Health Organization (WHO) recommends 200 hours of formal training for physicians who would like to incorporate acupuncture into their medical practices.
  • b. WHO suggests advanced training for physicians who desire more expertise in the field.
  • c. The 1997 National Institutes of Health (NIH) Consensus Statement supported acupuncture for postoperative and chemotherapy‐induced nausea and vomiting and for postoperative pain.
  • d. The first acupuncture practice regulations in the U.S. were written in the early 1800s.
  • e. An important aspect of safety in acupuncture practice is the ability of healthcare providers to respond effectively to medical emergencies.
• 2. Identify the incorrect statement:

  • a. The primary objective of this article was to understand whether acupuncture falls within the scope of practice for physicians in each state.
  • b. Similar to the practice of medicine in the United States, the practice of acupuncture is determined by each state.
  • c. In many states, the state medical board governs licensed physicians who provide acupuncture.
  • d. Regulations for acupuncture practice are established by federal laws.
  • e. An important aspect of safety in acupuncture practice is the ability of healthcare providers to recognize complications.
• 3. Identify the incorrect statement:

  • a. The majority of states identify acupuncture as within the scope of medical practice and therefore allow physicians to practice acupuncture under their medical licenses without further training.
  • b. Four states (Arkansas, Oklahoma, South Dakota, and Wyoming) have regulations that prohibit acupuncture practice by non‐physicians.
  • c. Regulations in three states (Hawaii, New Mexico, and Montana ) have stated that acupuncture is not automatically within the scope of physician practice and require a separate acupuncture license.
  • d. Eleven states identify acupuncture as within the scope of medical practice but require additional training specifically in acupuncture.
  • e. An important aspect of safety in acupuncture practice is the ability of healthcare providers to recognize contraindications.
• 4. Identify the incorrect statement:

  • a. Compared to the United States, other countries have different laws for the practice of acupuncture.
  • b. Unlike medical practitioners, acupuncturists in the United Kingdom are not subject to statutory regulation.
  • c. 2/3 of European countries require a medical license to practice acupuncture.
  • d. Acupuncture regulations in Canada are also determined by each province.
  • e. An important aspect of safety in acupuncture practice is the ability of healthcare providers to adhere to correct techniques.
• 5. Identify the incorrect statement:

  • a. While the majority of states allow non‐physicians to undergo training to receive acupuncture licenses, some prohibit this practice.
  • b. A common reason cited by physicians for performing acupuncture include its efficacy, usefulness in pain management, and failure of patients to fully respond to usual therapies.
  • c. Healthcare providers are increasingly recognizing that acupuncture is a valuable part of a multidisciplinary approach to complex diseases.
  • d. Currently all states conform with WHO recommendations for physician training in acupuncture.
  • e. An important aspect of safety in acupuncture practice is the ability of healthcare providers to appropriately select patients.

Continuing Medical Education – Journal Based CME Objectives:

Articles in Medical Acupuncture will focus on acupuncture research through controlled studies (comparative effectiveness or randomized trials); provide systematic reviews and meta‐analysis of existing systematic reviews of acupuncture research and provide basic education on how to perform various types and styles of acupuncture. Participants in this journal‐based CME activity should be able to demonstrate increased understanding of the material specific to the article featured and be able to apply relevant information to clinical practice.

CME Credit

You may earn CME credit by reading the CME‐designated article in this issue of Medical Acupuncture and taking the quiz online. A score of 75% is required to receive CME credit. To complete the CME quiz online, go to http://www.medicalacupuncture.org/cme – AAMA members will need to login to their member account. Non‐members have the opportunity to participate for a small fee.

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