To the Editor:

We read with great interest the recently published article titled, “Fear of analgesic side effects predicts preference for acupuncture: a cross-sectional study of cancer patients with pain in the USA” by Liou et al [1]. The authors concluded that acupuncture might be the preferable treatment option among cancer patients who are at risk of uncontrolled pain for fear of the side effects of analgesics. We would like to present some points for discussion regarding their conclusions.

First, we agree with the authors’ opinion that not investigating patients’ experience of acupuncture is a limitation of their study. We would also like to point out that patients’ experience of acupuncture is an important variable. The outcome of patients’ preference of acupuncture as a pain reduction treatment among cancer patients is likely to be influenced by their previous experiences with acupuncture for pain management (not necessarily for cancer). Therefore, it is assumed that participants who prefer acupuncture are more likely to have received acupuncture before and experienced pain relief. However, participants who have never experienced acupuncture before but have positive feelings about this treatment modality may gain pain relief by their positive emotions and attitude. According to Folkman, a modified coping process model suggests a relationship between positive emotions and reduced psychological stress [2]. Therefore, we would like to point out that positive feelings about acupuncture may lead to the acquisition of psychological stress relief, thereby raising the threshold for pain.

Second, the categorization of pain medication use in the analysis is questionable. If attitudinal barriers associated with fear of analgesic side effects are significantly related to acupuncture preferences, then we would suggest a detailed analysis of the types of opioids and other medications used.

Focus on non-pharmacological pain relief options for cancer patients with attitudinal barriers to pharmacological pain management is undoubtedly important. Hence, the study conducted by Liou et al. provides useful data. Our research group is similarly interested in the use of reflexology and aromatherapy as pain management options, considering the high feasibility of implementation of these potential pain relief treatments by clinical nurses. We believe that additional discussion of these questions could clarify the results of the study by Liou and colleagues.