Acupuncture: A Valuable Adjunct Therapy

Acupuncture: A Valuable Adjunct Therapy:

Michael O. Smith, MD, DAc

“Acu detox,” a simple and low-cost technique derived from acupuncture, is now used by approximately 1,000 addiction treatment programs in the United States and abroad. Clinical evidence supports its use in ameliorating withdrawal and craving symptoms of alcohol, opioid, and cocaine dependence, as well as symptoms associated with most other addictions. Acu detox is a foundation for later psychosocial recovery. It is a nonverbal, non-threatening, “first step” intervention that has an immediate calming effect on patients. Initial participation with acu detox has been found to improve patients’ overall treatment retention, and to facilitate their subsequent involvement.

This procedure has gained increasing acceptance from agencies responsible for overseeing addiction treatment. Currently, the U.S. Center for Substance Abuse Treatment (CSAT) is in the process of publishing a best practices statement for the modality.
Acu detox treatment for drug and alcohol problems was primarily developed at Lincoln Hospital, a New York City-owned facility located in the impoverished South Bronx. The Lincoln Recovery Center is a state- licensed treatment program facility that has provided more than 500,000 acu detox treatments in the past 20 years.

Acupuncture consists of the stimulation of specified locations on the surface of the body with the intention of altering and improving bodily function. Acupuncture points are physiologically distinct from the immediate environment: the precise location varies within a small area that corresponds to the acupuncture point as denoted on an acupuncture chart.

Acupuncture needles are stainless steel shafts of varying length and thickness. The needles used in addiction treatment penetrate 1/8 inch, contacting the cartilage if it is present in that location. The procedure is nearly painless and causes the rapid onset of a gratifying sense of relaxation. On first exposure, most patients express fear of the pain of needle insertion and are confused by the idea that little needles can cope with their big problems. This fear is easily solved by allowing prospective patients to observe other patients undergoing the actual process of treatment.
The standard formula seems to be equally effective for different addictive substances and at different stages of treatment. Patients respond better when acu detox treatment is administered quickly without a self- conscious, diagnostic prelude. Since acupuncture produces a homeostatic response, it is not necessary to adjust the formula for mood swings or agitation.

In most programs patients receive acupuncture in four or five points on the outer ear while seated together with other patients in a large group room. A group setting enhances the acu detox effect. A group size of less than six members seems to diminish symptoms of relief and retention significantly. Chemical dependency patients should remain in the group setting for approximately 40-45 minutes. While licensed acupuncturists (most of whom who have passed a national exam and have years of graduate-level education in the subject), often serve as providers in addiction programs, their high level of training is not required for delivering the routine acu detox protocol. Existing staff can learn the location of ear points and the technique of insertion through a 70-hour apprenticeship-based program. More than 10,000 addiction clinicians – counselors, social workers, nurses, medical doctors, and psychologists, etc. – have obtained the skills required to be an “acu detox specialist” or ADS. Training must include a clinical apprenticeship
because coping with the individual distractions and group process is more important and more difficult to learn than the technical skill of repetitive needle insertion. At present, a number of states allow for practice by these apprenticeship-trained addiction clinicians, including Arizona, Connecticut, Delaware, Indiana, Georgia, Idaho, Maryland, Michigan, Missouri, New York, Tennessee, and Texas.

Each ADS can provide about 15 treatments per hour in a group setting. General supervision should be provided by licensed acupuncturists who have taken the ADS training. This arrangement allows for acu detox to be integrated with existing services in a flexible and cost-effective manner. Core values of the acu detox program, as developed at Lincoln include: a supportive non-confrontational approach to individual counseling; an emphasis on Narcotics Anonymous and other 12-Step activities early in the treatment process; an absence of screening for appropriate patients; the use of herbal sleep mix; the use of frequent toxicologies; a willingness to work with court-related agencies; and a tolerant, informal, family-like atmosphere. Lincoln Hospital and the National Acupuncture Detoxification Association (NADA) have trained more than 10,000 ADS individuals. NADA was established in 1985 to increase the use of the Lincoln model and to maintain quality and responsibility in the field.

Controlled research:
H.L. Wen, MD, of Hong Kong, was the first physician to report successful use of acupuncture in the treatment of addiction withdrawal symptoms (Wen, 1973). He observed that opium addicts receiving electro-acupuncture as post-surgical analgesia experienced relief of withdrawal symptoms. Subsequently, Wen conducted several basic clinical pilot studies that formed the basis of subsequent research. Results from available placebo-design studies support the conclusion that acupuncture’s effectiveness in facilitating abstinence with alcohol, opiate, and cocaine abusers is not due to a simple placebo effect (Brewington,1994). Seven published studies involving animal subjects (i.e., mice or rats) indicate that electro-acupuncture (EA) reduces opiate withdrawal symptoms in morphine-addicted subjects. Significantly different hormonal and beta-endorphin levels post-EA are noted between experimental and control subjects in several of these studies.
A number of controlled studies have been conducted on human subjects using various modified versions of the acu detox protocol. Washburn (1993) reported that opiate-addicted individuals receiving correct site acupuncture showed significantly better program attendance relative to subjects receiving acupuncture located on placebo sites.
Bullock (1987) studied 54 chronic alcoholics randomly assigned to receive acupuncture either at points related to addiction or at nearby point locations not specifically related to addiction. Through-out the study, experimental subjects showed significantly better outcomes regarding attendance and their self-reported need for alcohol. Significant differences favoring the experimental group also were found regarding: 1) the number of self-reported drinking episodes, 2) self reports concerning the effectiveness of acu detox in affecting the desire to drink, and 3) the number of subjects admitted to a local detoxification unit for alcohol- related treatment. Bullock (1989), replicated Bullock (1987) using a larger (n=80) sample over a longer (six months) follow-up period. Twenty-one of 40 patients in the treatment group completed the eight-week treatment period as compared with one of 40 controls. Significant differences favoring the experimental group were again noted.

Placebo subjects self- reported over twice the number of drinking episodes reported by experimentals. In addition, placebo subjects were also readmitted to the local hospital alcohol detoxification unit at over twice the rate as experimental subjects during the follow-up period. Lipton (1994) conducted a placebo design experiment regarding the effectiveness of acu detox treatment for chronic cocaine/crack abuse. Subjects (n=150) were randomly assigned to receive either auricular acupuncture at correct sites, or acupuncture at nearby ear points not related to detoxification. Self-report measures and urinalysis profiles showed a significant tendency with both groups toward decreased cocaine consumption. Pretreatment cocaine/crack usage averaged about 20 days per month with all subjects. Self-reported use was reduced to an average of five days per month with both groups. Urinalysis profiles indicated superior outcomes with the experimental group during treatment. Over the course of treatment, experimental subjects showed a significant tendency toward greater day-to-day decreases in cocaine metabolite levels. Avants (2000) reported that randomly assigned, cocaine-dependent patients on methadone maintenance who received the basic ear acu detox treatment were much more likely to be cocaine-free at any point in the study period than were similar patients assigned to two control groups. One control group received needling at nearby ear points not related to detoxification and the other underwent a relaxation experience. Collated results of thrice-weekly urine screens showed the detox-specific group to be 3.41 times more likely to be negative on cocaine during the eight-week study regimen than the relaxation group, and 2.40 times more likely to be clean than the non-specific needling group. In the final week of the study regimen, 58.8 percent of those retained in the experimental group had negative toxicologies, versus 23.5 and 9.1 percent respectively, in the other two groups.

Clinical reports:
Acu detox is being used in diverse treatment settings. Unless otherwise noted, the following outcomes are based on clinical experiences at Lincoln Hospital or the author’s personal observation of other programs. Experience at Lincoln Hospital since 1974 shows that acu detox provides nearly complete relief of acute observable opiate withdrawal symptoms in five to 30 minutes. This effect lasts from eight to 24 hours. The duration of this effect increases with the number of serial treatments provided. Patients often sleep during the first session and may feel hungry afterward. Patients who are acutely intoxicated at the time acu detox is administered will behave in a much less intoxicated manner after the session. The addition of an acu detox component to an opiate detoxification program typically leads to a 50-percent increase in retention for completion of the recommended length of stay. For example, the Tulalip Tribe (in Washington) estimates a yearly saving of $148,000 due to less frequent referrals to hospital programs. Inpatient alcohol detoxification units typically combine acu detox and herbal “sleep mix” with a tapering benzodiazepine protocol. Patients have reported fewer symptoms and better sleep. Their vital signs indicate stability and, hence, there is much less use of benzodiazepines.

Woodhull Hospital in Brooklyn reported that 94 percent of the patients in the acu detox supplement group remained abstinent as compared to 43 percent of the control group who only received conventional outpatient services. Kent-Sussex Detoxification Center (in Delaware) reported a decrease in recidivism from 87 to 18 percent. Acu detox patients report more calmness and reduced craving for cocaine even after the first treatment. The acute psychological indications of cocaine toxicity are visibly reduced during the treatment session. This improvement is sustained for a variable length of time after the first acu detox treatment. After three to seven sequential treatments the anti- craving effect is more-or-less continuous as long as acu detox is received on a regular basis. Methadone maintenance patients re-ceive acupuncture in a number of different settings. Patients report a decrease in secondary symptoms of methadone use such as constipation, sweating, and sleep problems. Typically, there is a substantial drop in requests for symptomatic medication, and the treatment staff usually notices decreased hostility and increased compliance in methadone-acupuncture patients. The most important impact of acupuncture in maintenance programs is reduction of secondary substance use -primarily involving cocaine, but also alcohol (Margolin, 1993). At Lincoln, we have had a significant number of primary marijuana users seeking care. These patients usually report a rapid reduction in craving and improved mental well being. Secondary marijuana use is usually eliminated along with the detoxification of the primary drug (e.g., cocaine or heroin).

Women in Need, near Times Square in New York, reported the following outcome figures in their treatment for pregnant crack-using women: 1) Patients with conventional outpatient treatment averaged three visits per year. 2) Patients who took acu detox in addition to conventional treatment averaged 27 visits per year. 3) Patients who participated in an educational component in addition to acu detox and conventional treatment averaged
67 visits per year. Patients averaging three visits per year would be unlikely to participate in an educational component. Therefore, it seems likely that the increased retention correlated with acu detox set a foundation for successful participation in the educational component. The perception that a person can be both relaxed and alert is rather unusual in Western culture. We link relaxation with lazy or spacey behavior and alertness with a certain degree of anxiety. The relaxed and alert state is basic to the concept of health in Asian culture. Acupuncture encourages a centered, focused process that is typical of meditation and yoga. Therapists report that patients are able to listen and remember what they are told. Restless, impulsive behavior is greatly reduced, as are discouragement and apathy. It is a balancing, centering process. Acu detox is a non-verbal type of therapy, which is beneficial because acu detox is effective even when the patient is dishonest. Words and verbal relationships are not necessary components of this treatment. We do not mean that the therapist should not talk with the patient. Verbal interaction can be quite flexible so that a patient who does not feel like talking can be accommodated easily and naturally. Acu detox will be just as effective even when the patient lies to us.

The most difficult paradox in this field is that addicted persons usually deny their need for help. Nevertheless, resistant patients often find themselves in a treatment setting due to referral or other pressures. Acu detox can bypass much of the verbal denial and resistance that may otherwise limit retention of new and relapsed patients. Addicts are frequently ambivalent. Acu detox helps us reach the needy part of their psyche that wants help. Acu detox has the ability to reduce stress and craving, so that patients gradually become more ready to participate in the treatment process.

For further information, contact the National Acupuncture Detoxification Association (NADA), P.O. Box 1927, Vancouver WA 98662-5207. Phone: (888) 765-NADA; Fax: (360) 260-8620; e-mail: NADAClear@aol.com
Michael O. Smith, MD, DAc, a psychiatrist, is director of the Lincoln Recovery Center in Bronx, NY. He was a co-founder of the National Acupuncture Detoxification Association and is a frequent speaker and consultant for addiction treatment programs throughout the U.S. and many foreign countries.

References:

Avants, S.K., Margolin, A., Hofford, T.R., Kosten, T.R. (2000). A randomized controlled trial of auricular acupuncture for cocaine dependence, Archives of Internal Medicine, 160 (115). 2305-2312.

Bensky, D., O’Connor, G. (1986). Acupuncture: A Comprehensive Text, Eastland Press, Seattle, WA.

Brewington, V., Smith, M., Lipton, D. (1994). Acupuncture as a detoxification treatment: An analysis of controlled research. Journal of Substance Abuse Treatment, 11, (4) 298-307.

Bullock, M.L., Culliton, P.D., Olander, R.T. (1989). Controlled trial of acupuncture for severe recidivist alcoholism. Lancet, June 24, 1435-1439.

Bullock, M.L., Umen, A.J., Culliton, P.D., Olander, R.T. (1987). Acupuncture treatment of alcoholic recidivism: A pilot study. Alcoholism: Clinical and Experimental Research, 11 (3), 292-295.

Lipton, D.S., Brewington, V., Smith, M.O. (1994). Acupuncture for crack-cocaine detoxification: experimental evaluation of efficacy. Journal of Substance Abuse Treatment. 11 (3), 205-215.

Margolin, A., Avants, S.K., Chang, P., Kosten, T.R. (1993). Acupuncture for the treatment of cocaine dependence in methadone maintained patients. The American Journal on Addictions, 2 (3), 194-201.

Washburn, A.M., Fullilove, R.E., Fullilove, M.T., Keenan, P.A., McGee, B., Morris, K.A., Sorenson, J.L., Clark, W.W. (1993). Acupuncture heroin detoxification: A single-blind clinical trial. Journal of Substance Abuse Treatment, 10, 345-351.

Wen, H.L., Cheung, S.Y.C. (1973). Treatment of drug addiction by acupuncture and electrical stimulation. Asian Journal of Medicine, 9, 139-141.