Acupuncture for the Treatment of Addiction
Acupuncture for the Treatment of Addiction
By Robert J. Nardino, MD, FACP
Acupuncture was popularized in the western world after a New York Times reporter travelling with President Nixon’s entourage in China described his experience with acupuncture as anesthesia for an emergency surgical procedure. It was soon afterward that a patient of a Hong Kong neurosurgeon reported relief from opium withdrawal symptoms after acupuncture anesthesia.
The surgeon, Dr. H. L. Wen, went on to attempt acupuncture on other addicted patients and reported his findings in the mid-1970s.1 The most popular protocol was developed over years of use at Lincoln Hospital in the South Bronx, NY. Currently, many drug-treatment programs use acupuncture for management of drug addiction, particularly for drug addictions that have no highly effective treatment, such as cocaine addiction.
Traditional Use
Acupuncture is a therapeutic modality that has been used for thousands of years. Although texts of traditional Chinese medicine refer to its use in a wide variety of afflictions, they do not make reference to its use for addictive disorders.
Mechanism of Action
More so than other complementary therapies, there has been significant investigation into the mechanism of acupuncture.
Beta-endorphin levels, which play a role in pain control, were observed to rise in the brain tissue of mice when acupuncture was used to counteract the effect of naloxone-induced opiate withdrawal.2 Ulett and colleagues demonstrated that the withdrawal-preventive effect of electroacupuncture could be transferred to a second animal by infusing cerebrospinal fluid (CSF) from the animal receiving acupuncture. They also were able to prevent acupuncture-induced anesthesia by administering anti-endorphin antibodies.3 Continued investigation of the physiologic effects of acupuncture implicates stimulation of kappa-opioid receptors in the spinal cord.4 Andersson and Lundeberg have reported that the physiologic effects of acupuncture mimic those of vigorous exercise, including the release of endorphins and inhibition of the sympathetic system at the level of the hypothalamus.5
On the other hand, a study by Clement-Jones et al in heroin addicts showed that plasma endorphin and enkephalin levels did not change despite suppression of symptoms with acupuncture, although increased levels of CSF met-enkephalin were associated with successful acupuncture.6 Cortisol, adrenocorticotropic hormone, and cyclic adenosine monophosphate levels were reduced after auricular electroacupuncture.7
Despite all of this work, there is still disagreement about the exact mechanism.
Technique
Early use of acupuncture for addiction focused on the lung point (to see Figure, click here). Later, the shen men relaxation point was added. Most studies employ auricular acupuncture according to the National Acupuncture Detoxification Association (NADA) protocol, which specifies needle insertion in five regions, with the sympathetic, liver, and kidney added.
Sham or control acupuncture is much less standardized. Acupuncture points are based on the traditional Chinese medicine concept of the flow of qi. Because there is uncertainty about the mechanism of qi, it could be difficult to discern whether needling at non-acupuncture points lacks a physiological effect. However, to assess what could be a substantial placebo effect, it would appear to be important for control patients to receive sham acupuncture. There is ongoing research to better define active vs. control auricular acupuncture points.8
Clinical Studies
Alcohol. A 1990 meta-analysis by Ter Riet et al on acupuncture for addiction included two studies of alcohol-dependent patients. Although results seemed to favor treatment with acupuncture, the quality of the studies was poor: There was a lack of randomization in one study and an unacceptably high drop-out rate in the other.9 A subsequent randomized study of 56 alcoholics receiving acupuncture vs. sham acupuncture or standard care showed no benefit in terms of several outcome measures, although one-third of the patients also had addiction to other substances.10 Sapir-Weise et al reported a study of 72 alcoholics who were randomized to acupuncture or sham acupuncture; no significant difference in craving or drinking days was found.11
Overall, the data do not support the use of acupuncture for the treatment of alcohol dependence.
Cocaine. Acupuncture is used widely in cocaine treatment centers across the United States because the response to conventional treatment generally is poor. However, quality data are limited.
Bullock et al concurrently studied two groups with different controls.12 The first group of 236 patients in residential treatment was randomized to acupuncture at three auricular points vs. sham acupuncture or standard treatment. The second group of 202 ambulatory patients was randomized to acupuncture at five points for a varying duration of treatment. They found no significant differences in abstinence between acupuncture and control groups or between the different acupuncture regimens.
Another study by Avants et al was more promising.13 It reported the effectiveness of acupuncture on 82 cocaine-dependent patients who were receiving methadone maintenance. Patients were randomly assigned to receive acupuncture, sham acupuncture, or a relaxation control (passive imagery and music) with no needling. The acupuncture group received a variant of the NADA protocol, with only four points needled (lung, shen men, sympathetic, and liver). Patients received treatments five times per week over an eight-week period, with screening for cocaine use three times weekly.
The experimental group was more likely to submit cocaine-free urine samples; however, only 46% of the patients in the acupuncture group completed the eight-week treatment course. Nevertheless, intention-to-treat analysis showed a significant improvement in abstinence when acupuncture was compared with relaxation therapy and, when compared with sham acupuncture, the difference just reached significance.
A recently published randomized, multicenter trial similarly investigated auricular acupuncture as compared with needling of non-acupuncture sites or relaxation therapy.14 Six centers throughout the United States enrolled 620 patients. Treatments were offered five times per week for eight weeks. There was a high drop-out rate in all three treatment arms (45%). The main outcome measure was detection of cocaine metabolites by urine toxicology. In the intention-to-treat analysis, an overall modest reduction in cocaine use was seen, but there was no difference between acupuncture and the two control conditions. A limitation of the study may be that in an effort to be rigorous in design of the study, the treatment context may have differed from that used in practice.
The existing data do not confirm efficacy for treatment of cocaine addiction; further evaluation may be warranted to determine if acupuncture adds benefit to a program of psychosocial intervention.
Nicotine. The best summary of the evidence for acupuncture as a technique for smoking cessation comes from the Cochrane Collaboration.15 Only studies that randomized patients to acupuncture vs. sham acupuncture, another intervention, or no intervention were selected. A total of 18 studies met the criteria for inclusion. When acupuncture was compared to sham acupuncture, the odds ratio for the outcome of abstinence at six months was 1.38 (95% confidence interval [CI] 0.90-2.11) and at 12 months was 1.02 (95% CI 0.72-1.43), indicative of no effect. Likewise, there was no benefit compared to other interventions.
Despite widespread use, there is little evidence to support the use of acupuncture for smoking cessation.
Opiates. The Ter Riet meta-analysis reviewed five studies of acupuncture for heroin addiction, none of which were randomized.9 Since then, Washburn randomized 100 heroin addicts to acupuncture or sham acupuncture.16 Acupuncture patients attended the clinic more days than the control patients and stayed in treatment longer. Unfortunately, this study also suffered from a very high drop-out rate.
In another non-randomized study, Russell et al examined auricular acupuncture as an adjunct to substance abuse treatment in chronic repeat offenders.17 They followed 37 patients for 180 days looking at the endpoints of program retention, new arrests, drug-positive urine, and number of days to progress from entry level to secondary level of treatment. They used historical controls as the comparison, and found significantly improved program retention, although the impact diminished with time (30 days best, decreased over 30-day intervals until non-significant at 180 days). The other endpoints were better in the treatment cohort but did not reach statistical significance.
Finally, a retrospective study of patients seeking substance abuse treatment in Boston compared those who received acupuncture with those who participated in a residential program.18 The acupuncture group was less likely to require detoxification at six months, with an odds ratio of 0.71 (95% CI 0.53-0.95). However, the retrospective nature of the study allows for differences between the two groups, most importantly in regard to motivation to remain abstinent.
Overall, the data in support the use of acupuncture for treatment of heroin addiction are weak. A larger, well-designed RCT may clarify its efficacy.
Adverse Effects
Until recently, there has been a scarcity of data concerning the safety of acupuncture. Three British Medical Journal studies have improved this circumstance, although voluntary reporting and inclusion of only licensed acupuncturists may have produced under-reporting in both of these surveys.
White et al presented survey data from 78 physicians and physiotherapists in Great Britain who performed acupuncture.19 During 32,000 encounters, 43 events considered significant were reported (see Table, below); in addition, 2,135 minor events (predominantly minor bleeding and needling pain) also were reported.
MacPherson audited all 1,848 members of the British Acupuncture Council to report adverse events during a four-week interval in 2000.20 Among 574 acupuncturists participating, 43 adverse events were documented from 34,407 encounters (see Table), as well as 10,920 mild transient reactions.
Indeed, Ernst reviewed all of the adverse events reported worldwide in 1998 and noted just 11 serious complications, including fatal streptococcal myositis, acupuncture-induced angina, pneumothorax, and other infectious complications.21
In the setting of clinical trials, not only for addiction but also for a wide variety of medical problems, acupuncture is uniformly safe. The reports of White and MacPherson indicate event rates that are very low and compare very favorably with medication side effects; however, patients should be aware of a small potential for serious complications.
|
Table |
|||
| Adverse events attributed to acupuncture | |||
| Type of Event | Example | Number of Absolute Events | |
| White et al19 | MacPherson et al20 | ||
| (31,822 patients) |
(34,407 patients)* |
||
| Administration problem | Needle lost or forgotten | 7 | 2 |
| Application site problem | Cellulitis; needle allergy; needle site pain | 7 | 6 |
| Cardiovascular | Fainting | 6 | 5 |
| Gastrointestinal | Nausea; vomiting | 3 | 6 |
| General problems | Drowsiness; disorientation; lethargy; rash | 7 | 9 |
| Neuropsychological | Anxiety/panic; headache; paresthesia; seizure; slurred speech | 8 | 5 |
| Renal | Hematuria | — | 1 |
| Exacerbation of symptoms | Back pain; fibromyalgia; shoulder pain; migraine | 5 | 7 |
|
* Two adverse events in the MacPherson survey were unspecified. |
|||
Conclusion
Although acupuncture is widely available through numerous treatment programs, there is a paucity of well-executed randomized, controlled trials studying its effect in the treatment of addiction. The best-designed studies do not favor the use of acupuncture.
There appear to be two major methodological obstacles. First is the difficulty in selecting the control intervention. Sham acupuncture remains a poorly defined entity. Second is the difficulty of encouraging this population of patients to remain active study participants—studies consistently suffer from high drop-out rates.
At the present time, the available evidence does not support acupuncture for nicotine or alcohol addiction. The data for heroin need strengthening. Promising initial results in cocaine-addicted patients are in conflict with the negative results of a recent large multi- center trial.
Recommendation
In the hands of experienced practitioners, acupuncture generally is a safe procedure. Because of this, and because response to conventional treatment is poor, further study is warranted for acupuncture as an adjunct to the treatment of patients addicted to cocaine and opiates. Clinical use of acupuncture outside of clinical trials is not recommended.
Dr. Nardino is Program Director of the Internal Medicine Residency at the Hospital of Saint Raphael in New Haven, CT, and Assistant Clinical Professor of Medicine, Yale University School of Medicine.
References
1. Wen HL. Fast detoxification of heroin addicts by acupuncture and electrical stimulation (AES) in combination with naloxone. Complement Med East West 1977;5:257-263.
2. Wen HL, et al. The influence of electro-acupuncture on naloxone-induced morphine withdrawal. II. Elevation of immunoassayable beta-endorphin activity in the brain but not the blood. Am J Chin Med 1979;7: 237-240.
3. Ulett GA, et al. Electroacupuncture: Mechanisms and clinical application. Biol Psychiatry 1998;44:129-138.
4. Wu LZ, et al. Suppression of morphine withdrawal by electroacupuncture in rats: Dynorphin and kappa-opioid receptor implicated. Brain Res 1999;851:290-296.
5. Andersson S, Lundeberg T. Acupuncture—from empiricism to science: Functional background to acupuncture effects in pain and disease. Med Hypo-theses 1995;45:271-281.
6. Clement-Jones V, et al. Acupuncture in heroin addicts; changes in Met-enkephalin and beta-endorphin in blood and cerebrospinal fluid. Lancet 1979;2:380-383.
7. Wen HL, et al. Acupuncture in narcotic withdrawal: A preliminary report on biochemical changes in the blood and urine of heroin addicts. Bull Narc 1978:30:31-39.
8. Falk CX, et al. Preliminary results of a new method for locating auricular acupuncture points. Acupunct Electrother Res 2000;25:165-177.
9. Ter Riet G, et al. A meta-analysis of studies into the effect of acupuncture on addiction. Br J Gen Pract 1990;40:379-382.
10. Worner TM, et al. Acupuncture fails to improve treatment outcome in alcoholics. Drug Alcohol Depend 1992;30:169-173.
11. Sapir-Weise R, et al. Acupuncture in alcoholism treatment: A randomized out-patient study. Alcohol Alcohol 1999;34:629-635.
12. Bullock ML, et al. Auricular acupuncture in the treatment of cocaine abuse. A study of efficacy and dosing. J Subst Abuse Treat 1999;16:31-38.
13. Avants SK, et al. A randomized controlled trial of auricular acupuncture for cocaine dependence. Arch Intern Med 2000;160:2305-2312.
14. Margoin A, et al. Acupuncture for the treatment of cocaine addiction: A randomized controlled trial. JAMA 2002;287:55-63.
15. White AR, et al. Acupuncture for smoking cessation. Cochrane Database Syst Rev 2000;2.
16. Washburn AM, et al. Acupuncture heroin detoxification: A single-blind clinical trial. J Subst Abuse Treat 1993;10:345-351.
17. Russell LC, et al. Acupuncture for addicted patients with chronic histories of arrest. A pilot study of the Consortium Treatment Center. J Subst Abuse Treat 2000;19:199-205.
18. Shwartz M, et al. The value of acupuncture detoxification programs in a substance abuse treatment system. J Subst Abuse Treat 1999;17:305-312.
19. White A, et al. Adverse events following acupuncture: Prospective survey of 32,000 consultations with doctors and physiotherapists. BMJ 2001;323:485-486.
20. MacPherson H, et al. The York acupuncture safety study: Prospective survey of 34,000 treatments by traditional acupuncturists. BMJ 2001;323:486-487.
21. Ernst E, White AR. Acupuncture may be associated with serious adverse events. BMJ 2000;320:513-514.
Nardino RJ. Acupuncture for the treatment of addiction. 2002;5:42-46.Subscribe Now for Access
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