By Jeffrey A. Singer
for The State University of New York at Stony Brook, Spring, 1996
There is a struggle for legitimacy that Acupuncture used for treatment of Chemical Dependency has gone through. In order for Acupuncture to be considered a true or legitimate form of treatment, it must be accepted (endorsed) by the National Institute on Drug Abuse (NIDA). This has yet to happen. There is a distinct timeline pattern of research, both controlled and of a more casual nature.
A Practitioner's attempts to treat a patient in a fashion which would be successful, at many times conflicts with the guidelines for controlled research that the NIDA wants to see. Without this controlled research, the NIDA will not accept Acupuncture.
In my paper I will look at this timeline. I will also analyze the efforts that Acupuncture practitioners have made in order to gain the approval of the NIDA.
Acupuncture treatment of chemical dependency started, as do many discoveries, quite by accident. In 1972, Dr. H.L. Wen, a neurosurgeon in Hong Kong, was preparing a patient for surgery using electroacupuncture techniques. He had planned to apply electroacupuncture as surgical analgesia. The patient coincidentally was suffering from withdrawal symptoms from opium. The patient informed Dr. Wen that his withdrawal symptoms had subsided. Dr. Wen tested the procedure on other patients suffering from withdrawal symptoms, and their discomforts dissipated as well (Brown University 1993; Brumbaugh 1993; Turnabout A.S.A.P. 1995).
The news of this discovery made its way to the United States, and to Dr. Michael O. Smith of Lincoln Hospital. Lincoln Hospital is located in the South Bronx, New York City. Dr. Smith was involved in Methadone treatment, and was actively searching for alternatives. He hired Chinese doctors "to experiment with different protocols in the treatment of heroin addiction" (Brumbaugh 1993, 37). Smith started by using electroacupuncture, but soon switched over to manual Acupuncture, citing "more consistent clinical outcomes" (Brumbaugh 1993, 37).
Dr. Smith continued to use and refine the techniques. He expanded the program to treat not only heroin patients, but alcoholic patients and users of crack cocaine. In 1985, Dr. Smith started the National Acupuncture Detoxification Association, the NADA. Currently,
This is a group dedicated to providing the standards for using Acupuncture as a detoxification method. These standards ironically led to the slow acceptance of Acupuncture therapy. The standards stressed a laid back, stress free entrance into the detoxification treatment, similar to the classic Twelve Step Program. The protocol calls for the concept of empowering, in which the patients are involved in their own treatment. This could include, reading and tracking their own urinalysis, removing their own Acupuncture needles at the end of the treatment, and prepping the ear sites, where the needles will be placed, with alcohol. On a practical level, this put the chemically dependent person at ease, and willing to cooperate. On a purely research level this leads to the notion that there
"The National Acupuncture Detoxification Association, with 570 members, estimates that there are now 200 acupuncture detoxification programs in the United States and Europe" (Washburn 1993, 346).
"is a great need for... standardized methodology in the provision and study of Acupuncture," based on the potential inconsistencies created by such a loose set of protocols (McLellan 1993, 575).
Specifically, what is lacking, in researcher's terms, would be systematic clinical research. Specifics of what is missing, will be discussed later in this paper.
Based on Dr. Smith's work, and the creation of the NADA, there was a flurry of activity on both the treatment front and the research front, albeit the same loose research style as mentioned previously. Many Acupuncturists or Naturopathic Physicians began to include counseling and other forms of therapy into their treatment regimen (Aesoph 1993, 8). All of these practitioners claim to be using Dr. Smith's Lincoln Hospital system as a model.
A prime example of this is Dr. Lyn Patrick, of Tucson, Arizona,who treats nicotine addiction. Dr. Patrick uses counseling and Acupuncture treatment in combination with hiking, lectures, massage sessions and hydrotherapy. Dr. Patrick claims a seventy three percent success rate. She is basing this level of success on interviewing patients six months later, not on physical or chemical evaluations of the patients (Aesoph 1993). Needless to say, personal testimonials are insufficient on which to base a nationally accepted program.
Dr. Smith has undertaken many research studies to prove the system that he created at Lincoln Hospital. The very same system that is the foundation for the NADA itself. You might call it a self-justification.
Most reports of treatment at Lincoln Hospital have been primarily anecdotal, such as the following survey results reported in 1982 (Smith, et al. 1982):
- 90% relief of symptoms in acute withdrawal clients following acupuncture according to symptom surveys; 90% of all detoxification intake clients returned for further acupuncture treatment with no ancillary incentives such as other medications, welfare credit or probation merits; an estimated 60% of all acupuncture clients receiving the full series of treatments remained drug free for at least several months.
Smith cited budgetary limitations and an ever-increasing patient load as the reasons no formal statistical studies had been undertaken at that time (Ackerman 1993, 17).
In 1984, a large comparison study was conducted at the Haight Asbury Free Medical Clinic in San Francisco, California. This study compared 460 outpatients' results in Electroacupuncture by itself versus electroacupuncture used in conjunction with methadone treatment, versus methadone treatment alone. The choice of treatment modality was left up to the individual patient. Seventy two patients chose the Electroacupuncture alone. The study found that in relation to methadone treatment, electroacupuncture clients were more likely to drop out, citing pain at the stimulation sights. However, those who stayed with the Electroacupuncture exhibited a greater improvement than the methadone alone patients, especially in the areas of
Anxiety and depression. The combination treatment results were inconclusive. When a follow up of the successfully discharged patients was made, it was discovered that the Electroacupuncture treatments were far more successful for shorter term addicts than for longer term addicts (Ackerman 1993). The surprising thing about this particular study is how poorly received it was by the NADA, who historically accept anything that supports Acupuncture. The NADA complained that the use of two auricular Acupuncture points (versus the five that they suggest), could inherently skew the results (Smith 1988). Patients were also only seen individually, thus missing the peer support deemed to be very important. In addition, a class phenomenon seemed to exist whereby 'middle class whites' responded to acupuncture on an intellectual level while 'lower class minorities' were ostensibly alienated by the approach (Ackerman 1993, 20).
Further reading reading provides us with the meaning to that criticism. It was noted, that the seventy two patients who chose Electroacupuncture were predominantly white, highly educated, and employed, while the most of remainder were minorities of a lower socioeconomic bracket (Ackerman 1993). This differences in patient background highly affected the potential results of the study.
The question that has arisen from the early studies was the concept of the Placebo Effect. Was Acupuncture's success due in part to a psychological reinforcement by the practitioners ? Dr. Milton Bullock, (in one of the more highly acclaimed series of studies), addressed that issue. His 1989 study chose eighty patients from the Hennepin County Detoxification Center. Patients were chosen based on a strict set of criteria. This criteria included age, amount of prior admissions to the detoxification center, period of unemployment/unemployability, and previous inpatient or outpatient treatment failure. Very strict protocols were set up. As a blinded placebo study, only the Acupuncturists knew who was getting the real treatments. The patients, hospital personnel and the follow up coordinators were not given this information. All patients were paid to be in the study, provided they saw it to the end. The study was broken up into three phases of declining frequency of treatment, totaling eight weeks of treatment. The results were very promising. Over 52% of the patients being given the true treatments finished the study, only 2.5% of the patients from the control (placebo) group finished the study. This is a considerably high dropout rate of control patients, especially if you consider the promise of payment, if they finished the study. After six months, none of the treatment patients, who had completed the study, had been readmitted to the detoxification center, and 26% stated that they had not consumed any alcohol in that period of time. In the control group, 39 of the 40 patients either had reported episodes of alcohol use and/or had been readmitted into the detoxification center (Bullock, et al. 1989). An added bonus mentioned by Dr. Bullock was the potential savings in dollars.
... increased use of acupuncture therapy may eventually lead to a decrease in the number of inpatient admissions to expensive treatment centers. For example, the total cost for admissions to the detoxification center (average stay 30 h) for control patients over the six-month follow-up period was $20,424 higher than that of treatment patients (Bullock, et al. 1989, 1438).
It is interesting to note, that from this time forward, Bullock not Smith was looked upon as the standard of Acupuncture detoxification research. This is mainly due to the notion that before 1991, (you'll know why that date is important later in this paper), Bullock and his team were the only researchers to use a randomized, blinded form of research (Washburn 1993). This type of research is generally considered to be the best.
The quest for legitimacy by proponents of Acupuncture detoxification received a major boost in 1989. Dade County, Florida set up the nation's first drug court to deal with drug related problems. Multnomah County, Oregon soon followed with its own drug court. Both municipalities quickly began to incorporate Acupuncture detoxification into their programs as primary treatment. Dade County began first by introducing and in-jail pilot program. Inmates responded well to the treatments. While no clinical tests were performed, overall violence by inmates in the program was reduced. In Multnomah County, Acupuncture treatment was offered to nonviolent drug offenders as an alternative to serving jail time (Alcoholism and Drug Abuse Week 1994).
During the first year... 1,978 clients graduated from the yearling acupuncture program, while 1,570 clients were terminated. During the second year, the number of graduates climbed to 4,626, with termination dropping to 1,191 (Alcoholism and Drug Abuse Week 1994, 1).
In the third year of the program, Multnomah County, copied Dade County's lead, and introduced Acupuncture therapy to inmates. They also found that levels of violence among inmates strung out decreased dramatically. The long term benefits of this program are now coming to light.
Studies conducted by Multnomah County and American University in Washington, D.C. show the rearrest rate for non-graduates of the drug court treatment program to be almost four times higher than the rates for graduates (Alcoholism and Drug Abuse Week 1994, 2).
Most recently, Oakland County California has started to include Acupuncture therapy within its drug court system. In the Oakland program, it is not a primary form of treatment. Acupuncture is used only for those people continuing to fail other forms of drug treatment (Alcoholism and Drug Abuse Week 1994).
With all of this research and use in mind, (in addition to dozens not mentioned here), the NADA was very excited when the governing body of the treatment of chemical dependency (National Institute on Drug Abuse <NIDA>), held a technical review of the effectiveness of Acupuncture therapy. In order for Acupuncture to be considered a true or legitimate form of treatment, it must be accepted (endorsed) by the NIDA. Invited to attend the conference, held October 23, 1991, were many of the big names of Acupuncture research. They included Dr. Vincent Brewington (Dr. Michael Smith's partner at Lincoln hospital), Dr. Milton Bullock (the new champion of NADA's cause) , Dr. Janet Konefal (the doctor involved with Dade County's drug court program, Dr. Thomas Kosten (researcher from Yale University), and a few others from smaller programs and government agencies (McLellan 1993).
Speakers were allowed to make presentations during the conference. A representative from the Food and Drug Administration (Dr. Robert Munzer) discussed the legal status of Acupuncture needles, as experimental medical devices.
Acupuncture needles, officially, must be limited to investigational status until valid scientific evidence is obtained and presented to the FDA demonstrating that Acupuncture is a safe and effective technique for specific indications (McLellan 1993, 570).
This gave many of the NADA researchers a greater outlook, the could receive the NIDA and FDA approval all in one shot ! Their years of work could be given total validity. All of the panel speakers took turns describing their research, and handing out supporting data. The first problem arose based on the placement of the needles in the ear itself. The commonly accepted points, which have been known to give the best results in treatment of drug dependence are sympathetic, shen men, lung, kidney, and liver (Smith 1988).
These points have been determined... through traditional Chinese maps purporting to show representation of various bodily organs on the ears.... There is, however, no factual or scientific explanation for the selection of these five points (McLellan 1993, 571).
The next problem arose in the person of Dr. George Ulett of the Missouri Institute of Mental Health. His specialty was electrophysiological studies, the study of electrical activity in the body. His studies show that the introduction of electricity greatly increases the effectiveness of Acupuncture, well above the levels of manual Acupuncture. He went on to state that he
"regards acupuncture as frequency specific and not point specific, thus the location of needle placement is inconsequential, as long as the nervous system is stimulated"
(McLellan 1993, 571). This put researchers looking for the same outcome, on opposite sides.
Much to the disappointment of members of the NADA, the NIDA made its findings public:
It was disturbing to the panel to note that acupuncture treatment for opiate dependence had been critically evaluated in the 1970's and 1980's but that there had been very little methodologically solid work in the area during those two decades. Meanwhile, acupuncture procedures have been accepted and expanded over the same period of time and are now used in the treatment of cocaine and alcohol dependence. While some studies have emerged that were experimentally and clinically reasonable, the consensus was that much fundamental work remains to be done and that after two decades of contemporary use in the field of addiction, there is no compelling evidence for the efficacy of acupuncture in the treatment of either opiate or cocaine dependence. At the time of this meeting, the work of Bullock in the field of alcohol dependence represented the only methodologically sound suggestion of efficacy for the use of acupuncture for any dependence disorder.... This work, however, needs to be repeated (McLellan 1993, 575).
Much to the credit of the practitioners and researchers involved in Acupuncture for the treatment of chemical dependency, this major setback left them undaunted. They put their research into high gear, albeit a bit cautious. As you may understand, these researchers, who thought they were doing the correct thing all along, were quite taken aback by the NIDA's findings. They did not want a repeat of the Technical Review Board's findings. In order to facilitate this, the NIDA itself was asked for research assistance. The NIDA offered to assist in funding some of the studies, as long as it was involved in the research methodology decisions. However, "At less than $1,000,000 each, these are among the smallest of NIDA's current research grants" (Brumbaugh 1993, 41).
To date, the NIDA has been involved in three studies, and is beginning another later this year. The first study was headed by Dr. Douglas Lipton at the Lincoln Hospital Acupuncture Clinic. It was a four week study beginning in late 1991. The research examined the effectiveness of auricular Acupuncture in diminishing the craving and withdrawal symptoms of crack-cocaine users. A single blind technique in which daily Acupuncture or a placebo was given. The placebo was sham Acupuncture treatments (needles being placed in incorrect places). During this rather short term experiment, lessened cocaine use was reported by both groups. The experimental group showed greater reductions, but only by three percentage points. Such a small difference is not considered to be clinically significant (Brewington 1994; Millstein 1991).
Another study conducted by the NIDA was, and is still being done, by Dr. Janet Konefal of the University of Miami. Her study examines the efficacy of adding auricular Acupuncture and frequent urine testing to an existing drug abuse counseling program run by the Dade County's Drug Court. In an unblinded clinical trial three groups were followed through treatment: counseling alone, counseling plus frequent urine testing, and counseling along with frequent urine testing and Acupuncture. The results were most promising, but again raised new questions. The patients receiving Acupuncture showed a faster rate of obtaining clean urine samples, and a lower rate of drug recidivism. The question that arose, that opened a new can of worms, is why do men respond better to the Acupuncture treatments than women? Dr. Konefal's study had the unusual outcome of a far greater success rate among male patients than female patients, with no apparent explanation. Dr. Konefal is currently working on a new study where all patients receive Acupuncture treatments, but some receive the sham treatments. This study is similar to Dr. Lipton's, except that it includes the counseling and frequent urine testing mentioned earlier (Millstein 1991).
The third study began in January 1992 by Dr. Milton Bullock at the Hennepin County Medical Center. This study is very similar to Dr. Bullock's study of 1989. The NIDA, having found his earlier study to be methodologically sound, gave him the go ahead to repeat the research in an almost identical fashion. The results have not yet been published (Millstein 1994).
The first national study, slated to begin within the next few weeks, will analyze Acupuncture's effectiveness in cocaine treatment. The research is being conducted by Dr. Herbert Kleber of Columbia University. The three year program will examine the results of treatment of 600 patients at seven locations around the country. This study, (funded not only by the NIDA, but by several federal agencies and the Conrad Hilton foundation as well), will use two control groups. This is a departure from the standard, which is to use one control group. One control group will receive sham Acupuncture, the other will only receive relaxation therapy treatment. The study will endeavor to examine the effectiveness of the treatments after two weeks, six weeks, three months and six months. Patients will take drug tests along with other assessments. The study breaks the patients up into three groups: primary cocaine addicts, pregnant cocaine addicts (not eligible for standard Desipramine treatments), and cocaine users currently on methadone maintenance for a previous addiction. <NOTE: Desipramine is the most widely prescribed medication for cocaine addiction, but is unsafe for pregnant women> (Alcoholism and Drug Abuse week 1995).
My analysis of the literature on this topic leads me to believe that there is currently no conclusion. While Acupuncture therapy for the treatment of chemical dependency has been widely used for over twenty years, there is no absolute proof that it is truly effective. This is despite clinical research (some sloppy, some done well), many testimonials to its effectiveness, and being accepted by many of the criminal justice systems around the nation. The absolute proof required, seems to be at a higher standard than medical treatments used for other ailments. Are cancer medication treatments any more effective than Acupuncture therapy for drug addictions? If not, why is their use not as heavily questioned or criticized?
In my opinion, I believe in Acupuncture's effectiveness. I feel that the resistance to accept Acupuncture therapy is based, not on medicine, but on cultural bias.
This resistance, often tacit, like the Western Cultural resistance to Acupuncture in general, is understandable. Acupuncture, and the "invisible circulatory energy" paradigm of the organism upon which it is based, is implicitly nonrational. In that its basic premises about the body are based upon energic rather than somatic, it is in fundamental conflict with Western medical and scientific philosophy, from which current drug treatment strategies and theories have developed.
...acupuncture addresses addictive disorder on a "nonrationalistic" and subjective plane where the issues of recovery lie not in the relationship of the addict with the external world or "fix," but rather in relationship with self....
Oriental medicine characterizes addiction in terms such as "yin deficiency," "stuck liver chi," and "empty fire syndrome." Such unfamiliar and "nonmedical" tautology is not easily embraced by the "traditional" Western drug treatment establishment (Brumbaugh 1993, 41-42).
Ackerman, Ruth Watkins. 1993. Auricular Acupuncture treatment for chemical dependency. Paper presented to the National Acupuncture Detoxification Association, Inc.. Vancouver, Washington, 1-34.
Aesoph, Lauri M. 1993. Use Acupuncture to quit smoking. Natural Health , 12 July- August, 48-51.
Alcoholism and Drug Abuse Week. Acupuncture in drug courts: more than a needle exchange. 1994. 6 (August 15):1-2.
Alcoholism and Drug Abuse Week. Study will measure effectiveness of Acupuncture treatment. 1995. 7 (August 7):3-4.
Brewington, Vincent, Michael Smith and Douglas Lipton.
1994. Acupuncture as a detoxification treatment: An analysis of the controlled research. Journal of Substance Abuse Treatment 11:289-307.
Brown University Digest of Addiction Theory and Application. 1993. Acupuncture: overlooked approach that works. 12 (August):1-4.
Brumbaugh, Alex G. 1993. Acupuncture: new perspectives in chemical dependency treatment. Journal of Substance Abuse Treatment 10:35-43.
Bullock, Milton L., Patricia D. Culliton, and Robert T. Olander.
1989. Controlled trial of Acupuncture for severe recidivist alcoholism. The Lancet 8:1435-1439.
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1993. Acupuncture treatment for drug abuse: A technical review. Journal of Substance Abuse Treatment 10:569-576.
Miller, Jack. 1994. Solutions: An evaluation of an Acupuncture program for drug treatment in San Diego. Paper presented as an analysis of research to the faculty of Pacific College, Santa Monica. Internet: http://www.Acupuncture.com/Research/DrugSD.htm
Milstein, Richard A. 1994. Acupuncture and drug abuse. In Health Responsibility Systems, Collective Works & Database. Publication of the U.S. Department of Health and Human Serivces, National institutes of Health, Office of Alternative Medicine; 3(4).
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1982. Acupuncture treatment of drug addiction and alcohol abuse. American Journal of Acupuncture 10(2):161-163.
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1995. Acupuncture treatment for substance abuse. Santa Monica, 1-3.
Washburn, Allyson M., Robert E. Fullilove, Mindy Thompson Fullilove, et al.
1993. Acupuncture heroin detoxification: A single blind clinical trial. Journal of Substance Abuse Treatment 10:345-351.