Acupuncture & AddictionAcupuncture & Addiction

By Shahla Modir, MDBy Shahla Modir, MD

Addiction MedicineAddiction Medicine

UCLA Neuropsychiatric UCLA Neuropsychiatric InstituteInstitute

History of AcupunctureHistory of Acupuncture

Traditional Chinese Traditional Chinese MedicineMedicine

dates back 2500 dates back 2500 years years

4 components:4 components:– AcupunctureAcupuncture– Herbal medicineHerbal medicine– Tui NaTui Na– Qi gongQi gong

Chinese Medicine TheoryChinese Medicine Theory

Non-linear/Non-reductionist paradigmNon-linear/Non-reductionist paradigm

A part can only be understood in relation A part can only be understood in relation to the whole: dialectical logicto the whole: dialectical logic

TCM is based on Yin & Yang theoryTCM is based on Yin & Yang theory– Uses the constructs of the 2 polar Uses the constructs of the 2 polar

complementscomplements– Neither forces nor material entities Neither forces nor material entities

Identify how things function in relationship to each Identify how things function in relationship to each otherother

YinYin

Represents the element of waterRepresents the element of water

Associated with cold, rest, passivity, Associated with cold, rest, passivity, shade, tranquil, downward, decrease, shade, tranquil, downward, decrease, quiescencequiescence

The end, completion and fruitionThe end, completion and fruition

Present in the body and fluids, but also in Present in the body and fluids, but also in the natural environment the natural environment

YangYang

Represents the element of fireRepresents the element of fire

Associated with bright, heat, stimulation, Associated with bright, heat, stimulation, movement, excitement, vigor, light, up, movement, excitement, vigor, light, up, outward, increaseoutward, increase

It is arousal, beginning, and dynamic It is arousal, beginning, and dynamic potentialpotential

Present in the body and in the natural Present in the body and in the natural environmentenvironment

Yin and Yang TheoryYin and Yang Theory

Examples of Yin & YangExamples of Yin & Yang– Night/Day, Earth/Heaven, Fall & Winter/ Spring & Night/Day, Earth/Heaven, Fall & Winter/ Spring &

Summer, Male/Female, Cold/HotSummer, Male/Female, Cold/Hot– Acceptance & Responsiveness/Desire &WillfulnessAcceptance & Responsiveness/Desire &Willfulness

Yin and Yang control each other: if Yin is in Yin and Yang control each other: if Yin is in excess, yang will be too weakexcess, yang will be too weak

Yin and Yang transform into each otherYin and Yang transform into each other– Harmonious change as a natural cause of eventsHarmonious change as a natural cause of events– Sudden rupture and transformation of extremely Sudden rupture and transformation of extremely

disharmonious situationsdisharmonious situations

Yin and YangYin and Yang

Balanced HealthBalanced Health

People are constantly bombarded in the natural universe with People are constantly bombarded in the natural universe with changes in Yin and Yang:changes in Yin and Yang:– daily cycles, seasonal changes, food and lifestyle choicesdaily cycles, seasonal changes, food and lifestyle choices– all affect the organisms balance of yin/yangall affect the organisms balance of yin/yang

When the amount of Yin and Yang are relatively balanced When the amount of Yin and Yang are relatively balanced – a state of health and equanimitya state of health and equanimity

When there are unequal portions of Yin and Yang in the systemWhen there are unequal portions of Yin and Yang in the system– leads to disharmony in the body and mind and symptoms or correlates leads to disharmony in the body and mind and symptoms or correlates

of diseaseof diseaseExtreme disharmony means that the deficiency of one aspect can Extreme disharmony means that the deficiency of one aspect can not continue to support the excess of the other aspect not continue to support the excess of the other aspect – Extreme high fever leading to shock and hypothermiaExtreme high fever leading to shock and hypothermia– Relationship of an extreme passive person with an aggressive personRelationship of an extreme passive person with an aggressive person

Macrocosmic QiMacrocosmic Qi

Fundamental to TCM and Chinese culture, but Fundamental to TCM and Chinese culture, but difficult to capture the meaningdifficult to capture the meaningAll in the universe that is organic, inorganic is All in the universe that is organic, inorganic is defined by its qidefined by its qi– Mountains, plants, human emotionMountains, plants, human emotion– Vital energy, a kind of matter on the verge of Vital energy, a kind of matter on the verge of

becoming energybecoming energy– The thread connecting all beings, the potential of and The thread connecting all beings, the potential of and

actualization of transformationactualization of transformation– Does not cause change but is present before, during , Does not cause change but is present before, during ,

and afterand after

Microcosmic QiMicrocosmic Qi

Qi in an applied practical setting of the Qi in an applied practical setting of the human organismhuman organism– Means the dynamic of engendering Means the dynamic of engendering

movement, tension, activation (yang aspect)movement, tension, activation (yang aspect)

3 sources of Qi3 sources of Qi– Original Qi: (Yuan qi) inherited or ancestral qiOriginal Qi: (Yuan qi) inherited or ancestral qi– Grain Qi: (Gu-qi) derived from foodGrain Qi: (Gu-qi) derived from food– Natural Qi: (Kong qi) extracted by lungs from Natural Qi: (Kong qi) extracted by lungs from

the airthe air

Qi in the bodyQi in the body

5 functions of Qi5 functions of Qi– Source of all Source of all

movement & movement & accompanies itaccompanies it

– Protects the bodyProtects the body– Source of harmonious Source of harmonious

transformationstransformations– Ensures stability and Ensures stability and

governs retentiongoverns retention– Warms the bodyWarms the body

5 primary types of Qi5 primary types of Qi– Organ qiOrgan qi– Meridian qiMeridian qi– Nutritive qiNutritive qi– Protective qiProtective qi– Ancenstral qiAncenstral qi

Meridians (Jing-luo)Meridians (Jing-luo)

Jing meaning to go through or thread in a fabricJing meaning to go through or thread in a fabricLuo meaning something that connects or attachesLuo meaning something that connects or attachesMeridians are the 12 pathways that carry qi and blood Meridians are the 12 pathways that carry qi and blood through the body; they are not blood vessels or nervesthrough the body; they are not blood vessels or nervesA subtle energetic lattice that links together the A subtle energetic lattice that links together the fundamental textures to the organs and unifies all parts fundamental textures to the organs and unifies all parts of the bodyof the bodyEssential for harmonious flow to occur in order to Essential for harmonious flow to occur in order to regulate the flow of the yin and yang, move qi and blood, regulate the flow of the yin and yang, move qi and blood, moisten the tendons and bones, and benefit the jointsmoisten the tendons and bones, and benefit the jointsImbalanced (too much or too little) yin or yang in the Imbalanced (too much or too little) yin or yang in the flow, blocked flow, insufficient/excess qi all create flow, blocked flow, insufficient/excess qi all create disharmony and diseasedisharmony and disease

AcupunctureAcupuncture

The Meridian system The Meridian system 12 regular meridians that correspond to each of 12 regular meridians that correspond to each of

the 5 Yin and 6 Yang organs and to the the 5 Yin and 6 Yang organs and to the PericardiumPericardium

Insertion of very fine needles into points Insertion of very fine needles into points along the meridian can rebalance the along the meridian can rebalance the bodies disharmoniesbodies disharmonies

Auricular AcupunctureAuricular Acupuncture

Auricular acupuncture is a variantAuricular acupuncture is a variantassumes that the body is like a holograph and assumes that the body is like a holograph and

is represented entirely on the ear.is represented entirely on the ear.

the map was created based on the experience the map was created based on the experience of 50,000 soldiers in the Nan Jing armyof 50,000 soldiers in the Nan Jing army

the needles are inserted 1-3 millmeters and the needles are inserted 1-3 millmeters and withdrawnwithdrawn

Auricular AcupunctureAuricular Acupuncture

Landmark StudiesLandmark Studies

Neuronal specificity of Neuronal specificity of acupuncture response: acupuncture response: an fMRI study with EAan fMRI study with EA– Study of 15 healthy Study of 15 healthy

volunteers using mock EA volunteers using mock EA (no EA), minimal EA at real (no EA), minimal EA at real acupoints used for acupoints used for analgesia, sham EA (real analgesia, sham EA (real EA at non-meridian pointsEA at non-meridian points

– The limbic system showed The limbic system showed significant modulation by significant modulation by EA at analgesic acupoints EA at analgesic acupoints rather than non-meridian rather than non-meridian pointspoints

Correlation between Correlation between acupoints and acupoints and corresponding brain corresponding brain cortices on fMRIcortices on fMRI– 12 healthy volunteers 12 healthy volunteers

stimulated visual acupoints stimulated visual acupoints – Found correlations Found correlations

between the activation of between the activation of specific visual cortex and specific visual cortex and the corresponding acupoint the corresponding acupoint stimulation predicted by the stimulation predicted by the acupuncture literatureacupuncture literature

Acupuncture and AddictionAcupuncture and Addiction

Chinese neurosurgeon HL Wen in 1972 Chinese neurosurgeon HL Wen in 1972 discovered benefits on accidentdiscovered benefits on accident– Noticed that acupuncture pain treatments in post-Noticed that acupuncture pain treatments in post-

surgical, opiate addicted patients seemed to alleviate surgical, opiate addicted patients seemed to alleviate withdrawalwithdrawal

– Used EA of lung point in 40 patients with opiate Used EA of lung point in 40 patients with opiate addiction found uniform decreases in opiate addiction found uniform decreases in opiate withdrawal symptomswithdrawal symptoms

Pomeranz et al found EA in rats significantly Pomeranz et al found EA in rats significantly reduced the signs of morphine withdrawalreduced the signs of morphine withdrawal– Supports work of Ng, Thoa, and Albert that showed Supports work of Ng, Thoa, and Albert that showed

auricular EA significantly reduced signs of naloxone-auricular EA significantly reduced signs of naloxone-induced withdrawal in morphine dependent ratsinduced withdrawal in morphine dependent rats

NADA protocolNADA protocol

Michael Smith, a psychiatrist in the Bronx, N, Michael Smith, a psychiatrist in the Bronx, N, modified Wen’s protocol by eliminating the EA modified Wen’s protocol by eliminating the EA and abbreviating the prescription to five and abbreviating the prescription to five auricularauricular needles needles This prescription was not designed for This prescription was not designed for withdrawal from any particular drugwithdrawal from any particular drugInstead designed to reduce anxiety, craving, and Instead designed to reduce anxiety, craving, and dysphoria during the early weeks of withdrawaldysphoria during the early weeks of withdrawalMeant to make acupuncture more accessible Meant to make acupuncture more accessible and affordableand affordable

NADA protocolNADA protocol

National Acupuncture National Acupuncture Detoxification AssociationDetoxification Association

800 treatment centers 800 treatment centers use this protocol use this protocol

Many studies use some Many studies use some variant of the protocol variant of the protocol which states 3-5 points which states 3-5 points should be usedshould be used

Uses 5 points in bilateral Uses 5 points in bilateral auricles left in place for auricles left in place for 40 minutes and removed40 minutes and removed

Points: Points:

Shen MenShen Men

SympatheticSympathetic

LungLung

LiverLiver

KidneyKidney

Acupuncture Study DesignAcupuncture Study Design

Problems with designing acupuncture studiesProblems with designing acupuncture studies1.1. Single blindedSingle blinded2.2. Control points are usually active “unrelated” Control points are usually active “unrelated”

pointspoints3.3. No inert treatments in TCM model; paradigm No inert treatments in TCM model; paradigm

mismatchmismatch4.4. Ulett (1992) from Western perspective argued Ulett (1992) from Western perspective argued

auricular acupuncture effect due to stimulation auricular acupuncture effect due to stimulation of the vagus nerve that innervates the entire of the vagus nerve that innervates the entire concha & thus needles anywhere on the concha & thus needles anywhere on the concha will produce an effectconcha will produce an effect

Opiate detoxificationOpiate detoxification

Washburn, Keenan, and Nazareno (1990) Washburn, Keenan, and Nazareno (1990) reported on study 100 subjects with opiate reported on study 100 subjects with opiate dependence randomly assigned to receive dependence randomly assigned to receive acupuncture or sham acupunctureacupuncture or sham acupunctureOutpatient, 21 day detox programOutpatient, 21 day detox programExp’tl subjects showed significantly better Exp’tl subjects showed significantly better attendance and remained in treatment for longer attendance and remained in treatment for longer periods than controlsperiods than controlsHowever only 7% of exp’tal grp and 4% of the However only 7% of exp’tal grp and 4% of the placebo group tested negative for opiates after 2 placebo group tested negative for opiates after 2 weeksweeks

Opiate detoxificationOpiate detoxification

Clark (1990)Clark (1990)

N=84 opiate dependent N=84 opiate dependent chose either methadone chose either methadone or acupunctureor acupuncture

Methadone was gradual Methadone was gradual decrease over 21 daysdecrease over 21 days

42 pairs subjects 42 pairs subjects matched age, race, and matched age, race, and sexsex

ResultsResults

At 90 day f/u:At 90 day f/u:– 31% acupuncture subj 31% acupuncture subj

drug free/ 53% pos drug free/ 53% pos U/AU/A

– 14% methadone subj 14% methadone subj drug free/ 62% pos drug free/ 62% pos U/AU/A

Opiate DetoxificationOpiate Detoxification

Greiger 1987Greiger 1987

65 incarcerated 65 incarcerated opiate dependentsopiate dependents

Randomly assignedRandomly assigned– Methadone detox with Methadone detox with

acupunctureacupuncture– Methadone detox Methadone detox

without acupuncturewithout acupuncture

Results:Results:Methadone with Methadone with acupuncture reported acupuncture reported significantly less significantly less withdrawal symtoms withdrawal symtoms (stomach cramps, (stomach cramps, diarrhea, h/a, diarrhea, h/a, depression)depression)No placebo arm of the No placebo arm of the studystudy

Alcohol detoxificationAlcohol detoxification

Two placebo-design Two placebo-design studies studies – Bullock (1987) studied 54 Bullock (1987) studied 54

chronic alcohol abusers chronic alcohol abusers and randomly assigned to and randomly assigned to receive acupoints or near receive acupoints or near by acupoints (non detox by acupoints (non detox oriented)oriented)

Inpatient setting, free to Inpatient setting, free to leave each day, alcohol leave each day, alcohol consumption not excludedconsumption not excluded

2 ½ months of treatment2 ½ months of treatment

ResultsResults– Throughout study Throughout study

experimental subjects experimental subjects showed better attendance showed better attendance and decreased self report and decreased self report need for alcoholneed for alcohol

– After 2After 2ndnd week of tx, exp’tal week of tx, exp’tal group reported decreased group reported decreased number of drinking number of drinking episodes, decreased episodes, decreased number of subjects number of subjects admitted to a local detox admitted to a local detox unit for alcohol txunit for alcohol tx

Alcohol detoxificationAlcohol detoxification

Bullock et al (1987) Bullock et al (1987) replicated using a replicated using a larger samplelarger sample

N=80 with subject N=80 with subject interviews at 1,3, and interviews at 1,3, and 6 months post 6 months post treatmenttreatment

2 months of treatment2 months of treatment

ResultsResults– Acupuncture group Acupuncture group

showed greater showed greater retention in treatmentretention in treatment

– During the 1,3, and 6 During the 1,3, and 6 month f/u interviews, month f/u interviews, exp’tal subjects exp’tal subjects expressed expressed

Less need for alcoholLess need for alcoholLess self reported Less self reported drinking episodesdrinking episodesGreater self reported Greater self reported abstinenceabstinence

Cocaine detoxificationCocaine detoxification

Lipton, Brewington, and Smith Lipton, Brewington, and Smith (1990) conducted a placebo (1990) conducted a placebo designed studydesigned study– 150 cocaine/crack abusers 150 cocaine/crack abusers

entering a substance abuse entering a substance abuse program program

– randomly assigned to receive randomly assigned to receive auricular acupuncture at auricular acupuncture at correct sites or nearby points correct sites or nearby points not related to detoxificationnot related to detoxification

– Treatments provided for 1 Treatments provided for 1 month and urine tox were month and urine tox were provided after each sessionprovided after each session

– Interviews at 30 and 90 days Interviews at 30 and 90 days after treatment were after treatment were conductedconducted

ResultsResults– Self report measures and U/A Self report measures and U/A

profiles showed a significant profiles showed a significant tendency with both groups tendency with both groups toward decreased cocaine toward decreased cocaine consumptionconsumption

– Pre-tx cocaine/crack usage Pre-tx cocaine/crack usage ave at 20 days/month with all ave at 20 days/month with all subjects. During tx period and subjects. During tx period and at 3 mos post tx self report at 3 mos post tx self report use was reduced to 5 use was reduced to 5 days/month with both grpsdays/month with both grps

– Tx retention throughout the Tx retention throughout the experiment did not differ experiment did not differ

– U/A profiles indicated superior U/A profiles indicated superior outcomes with the exp’tl grp outcomes with the exp’tl grp during tx & showed more during tx & showed more cocaine negative urines over cocaine negative urines over the course of tx (24% vs 21).the course of tx (24% vs 21).

Further resultsFurther results

Subjects in the study did not routinely get Subjects in the study did not routinely get counseling. Each morning, the clinic accepted counseling. Each morning, the clinic accepted into tx the first 3 people and they were put in into tx the first 3 people and they were put in therapy and acupuncture. Later walk ins therapy and acupuncture. Later walk ins received acupuncture alone.received acupuncture alone.Urine profiles of the 73 subjs who received Urine profiles of the 73 subjs who received correct site acupuncture were compared with 42 correct site acupuncture were compared with 42 clinic pts who received counseling and clinic pts who received counseling and acupunctureacupunctureResults showed drop out/retention rates were Results showed drop out/retention rates were the same but 50% of counseling/acu pts had neg the same but 50% of counseling/acu pts had neg cocaine urines vs. 24% for acu only ptscocaine urines vs. 24% for acu only pts

Cocaine AddictionCocaine Addiction

Margolin 2000Margolin 200082 cocaine dependent, methadone maintained 82 cocaine dependent, methadone maintained patients/ oupt programpatients/ oupt programRandom assignmentRandom assignment– Auricular acupuncture 4 pointsAuricular acupuncture 4 points– Auricular control 4 pointsAuricular control 4 points– Relaxation control: videos and relaxation trainingRelaxation control: videos and relaxation training– 5x/ week for 8 weeks5x/ week for 8 weeks– No financial incentiveNo financial incentive– 40 min of each tx, after methadone dose40 min of each tx, after methadone dose

ResultsResults

Patients assigned to Patients assigned to acupunctureacupuncture group group significantly significantly more likelymore likely to provide to provide cocaine negative urinescocaine negative urines compared to compared to both the needle control and relaxation both the needle control and relaxation training.training.– P=.01P=.01– odds ratio 3.41odds ratio 3.41– confidence interval 1.33-8.72confidence interval 1.33-8.72

Cocaine/Opiate AddictionCocaine/Opiate Addiction

Margolin (2002) Margolin (2002)

RCT single blind/ outpatient studyRCT single blind/ outpatient study

6 community based clinics :6 community based clinics :– 3 hospital affiliated/3 methadone maintenance3 hospital affiliated/3 methadone maintenance

N=620 Adults, ave. age= 38.8N=620 Adults, ave. age= 38.8

412=cocaine only 208=opiate & cocaine 412=cocaine only 208=opiate & cocaine

Cocaine and OpiateCocaine and Opiate

Random assignment to 3 armsRandom assignment to 3 arms– Auricular acupuncture = 222Auricular acupuncture = 222– Needle control auricular = 203Needle control auricular = 203– Relaxation training = 195Relaxation training = 195– Treatments 5X/week for 8 weeksTreatments 5X/week for 8 weeks– Paid 2$/session and 10$/weekPaid 2$/session and 10$/week– Drug counseling “N.A.” provided not required Drug counseling “N.A.” provided not required

ResultsResults

Intent to tx analysis of U/A showed decreased Intent to tx analysis of U/A showed decreased cocaine use in all 3 groups p=.002cocaine use in all 3 groups p=.002

No between group differencesNo between group differences

No differences in treatment retention 44%-46% No differences in treatment retention 44%-46% for 8 weeksfor 8 weeks

Counseling ie, NA was poorly attended for allCounseling ie, NA was poorly attended for all

Authors state that a model of just acupuncture Authors state that a model of just acupuncture without more intensive psychosocial tx led to without more intensive psychosocial tx led to poor outcome; subj population also very difficultpoor outcome; subj population also very difficult

Methamphetamine and Methamphetamine and AcupunctureAcupuncture

No single study reports in the literatureNo single study reports in the literatureOnly one found uses data collected on patients Only one found uses data collected on patients with chronic arrest history and drug abuse: non-with chronic arrest history and drug abuse: non-randomized, no placebo acupuncturerandomized, no placebo acupuncture37 patients received acupuncture during early 37 patients received acupuncture during early weeks of tx and were followed for 180 days post weeks of tx and were followed for 180 days post admissionadmissionThese data were compared to archived These data were compared to archived information from 49 no acupuncture patients information from 49 no acupuncture patients who entered tx the 5 mos before it was availablewho entered tx the 5 mos before it was availableTotal of 86 subjects completed: MA drug of Total of 86 subjects completed: MA drug of choice for 44/86 subjectschoice for 44/86 subjects

ProtocolProtocol

Acupuncture protocol:Acupuncture protocol:– NADA auricular protocol daily for 3 weeks NADA auricular protocol daily for 3 weeks

then M,W,F for 4 weeks, then M, T for 2 then M,W,F for 4 weeks, then M, T for 2 weeksweeks

– During tx, no talking, sitting in recline chairs During tx, no talking, sitting in recline chairs with soft music for 45 minuteswith soft music for 45 minutes

Non-AC protocol: Tx as usualNon-AC protocol: Tx as usual

ResultsResults

AC patients significantly AC patients significantly higher program retention higher program retention than NA patients at day #:than NA patients at day #:– 30 (p>0.0001)30 (p>0.0001)– 60 (p>.002), 60 (p>.002), – 90 (p>.001), 90 (p>.001), – 120 (p>.007),120 (p>.007),– 150 (p>.031) 150 (p>.031)

At 180 days a higher % At 180 days a higher % AC than NA pts remained AC than NA pts remained in tx, not significantin tx, not significant

In AC pts: decreased # of In AC pts: decreased # of new arrests, drug positive new arrests, drug positive U/A, but not significantU/A, but not significant

Regardless of tx condition Regardless of tx condition – MA pts had lower program MA pts had lower program

retention overall retention overall – AC improved the retention AC improved the retention

only up to 30 days (p>.021)only up to 30 days (p>.021)

Does AC not work in this Does AC not work in this population or is more tx population or is more tx rqr’d?rqr’d?

Acupuncture MechanismAcupuncture Mechanism

Clement-Jones et al (1979)Clement-Jones et al (1979)

Examined EOP levels in 5 grps of subjsExamined EOP levels in 5 grps of subjs– 6 heroin dep with mild withdrawal who rcv’d EA and 6 heroin dep with mild withdrawal who rcv’d EA and

gave bld and CSFgave bld and CSF– 6 heroin dep with severe withdrawal; No EA but gave 6 heroin dep with severe withdrawal; No EA but gave

bldbld– 7 hospitalized pts (unspecified conditions) –provided 7 hospitalized pts (unspecified conditions) –provided

CSfCSf– 25 healthy volunteers; gave blood25 healthy volunteers; gave blood– 18 hospitalized pts with non-endocrine dz; gave blood18 hospitalized pts with non-endocrine dz; gave blood

ResultsResults

Heroin dep subj basal B-endorphin levels higher Heroin dep subj basal B-endorphin levels higher in both blood and CSF vs. non-addicted ptsin both blood and CSF vs. non-addicted pts

Addicted subj’s bld and CSF B-endorphin levels Addicted subj’s bld and CSF B-endorphin levels not change significantly with EAnot change significantly with EA

Basal met-enkephalin level of heroin addicted Basal met-enkephalin level of heroin addicted pts not differ from non-addictedpts not differ from non-addicted

EA tx of heroin addicts led to rise in CSF met EA tx of heroin addicts led to rise in CSF met enkephalin level but no change in blood met-enkephalin level but no change in blood met-enkephalin levelsenkephalin levels

Acupuncture MechanismAcupuncture Mechanism

Wen et al 1978aWen et al 1978a

8 heroin dependent females undergoing 8 heroin dependent females undergoing detox detox

6 non-abusing controls6 non-abusing controls

Measured blood levels of: ACTH, cortisol, Measured blood levels of: ACTH, cortisol, c-AMP and urine aldosterone, c-AMP and urine aldosterone, catecholamines, VMA, cortisol, and cAMPcatecholamines, VMA, cortisol, and cAMP

DesignDesign

Heroin abusing subjects received Heroin abusing subjects received methadone decreasing over 10 day period methadone decreasing over 10 day period (30 mg-10 mg)(30 mg-10 mg)

On days 4-10 no additional medication On days 4-10 no additional medication given, but subj received EA 3x/daygiven, but subj received EA 3x/day

Non-abusing controls received EA on days Non-abusing controls received EA on days 4-10 3x/day4-10 3x/day

ResultsResults

Heroin addicted subjects showed Heroin addicted subjects showed significant reduction post EA in plasma significant reduction post EA in plasma cortisol, ACTH, c-AMPcortisol, ACTH, c-AMPNormal control subjects post EA showed Normal control subjects post EA showed decreased ACTH, cortisol decreased ACTH, cortisol Previous research has shown that heroin Previous research has shown that heroin abusing subjects in withdrawal normally abusing subjects in withdrawal normally have increased plasma cortisol-not have increased plasma cortisol-not decreaseddecreased

Acupuncture MechanismAcupuncture Mechanism

Wen et al 1978bWen et al 1978b

Replicated study Replicated study

N=40 heroin dep subjs/ N=31 non-dependantN=40 heroin dep subjs/ N=31 non-dependant

Measured changes in cortisol, ACTH, c-AMP pre Measured changes in cortisol, ACTH, c-AMP pre versus post EAversus post EA

Found significant decrease in cortisol/ACTH Found significant decrease in cortisol/ACTH levels post EA in heroin dep subj during detoxlevels post EA in heroin dep subj during detox

No changes were found in the non-dependent No changes were found in the non-dependent controls post EAcontrols post EA

Acupuncture Mechanism: c-FosAcupuncture Mechanism: c-Fos

Purpose of the study to evaluate whether AC Purpose of the study to evaluate whether AC could affect the fxn’al alterations of the meso-could affect the fxn’al alterations of the meso-limbic dopaminergic system involved in the limbic dopaminergic system involved in the nicotine –induced behavioral sensitization in rats nicotine –induced behavioral sensitization in rats and if AC would decrease the expected increase and if AC would decrease the expected increase in nicotine-induced locomotor activityin nicotine-induced locomotor activity35 male rats randomly divided 8 days prior to 35 male rats randomly divided 8 days prior to procedureprocedureRepeat nicotine grps were pre-tx’ed with nicotine Repeat nicotine grps were pre-tx’ed with nicotine 2x/day X 7 days and then were systemically 2x/day X 7 days and then were systemically challenged with nicotine on day 11challenged with nicotine on day 11Drugs were not injected on days 8-10Drugs were not injected on days 8-10

ProtocolProtocol

The saline tx’d grp rcv’d saline for 7 days The saline tx’d grp rcv’d saline for 7 days and was challenged with salineand was challenged with saline

The expt’al grp rcv’d acupuncture at St 36, The expt’al grp rcv’d acupuncture at St 36, HT 7, or LU 9 during the withdrawal periodHT 7, or LU 9 during the withdrawal period

The control grp did not rcv any tx other The control grp did not rcv any tx other than a slight grab during the withdrawalthan a slight grab during the withdrawal

All groups were challenged with systemic All groups were challenged with systemic nicotine at day 11nicotine at day 11

ResultsResults

Behavioral analysis: rats given Behavioral analysis: rats given repeat nicotine showed repeat nicotine showed increased beh response when increased beh response when given nicotine challenge given nicotine challenge compared to saline ratscompared to saline ratsDuring the nicotine w/d period, During the nicotine w/d period, AC at ST 36 , but not the other AC at ST 36 , but not the other AC points attenuated the AC points attenuated the expected increase in nicotine expected increase in nicotine induced locomotor activity to induced locomotor activity to subsequent nicotine subsequent nicotine challengeschallenges

Beh response to the nicotine Beh response to the nicotine challenge in the repeat challenge in the repeat nicotine grp was higher than in nicotine grp was higher than in the acute nicotine grp(p>.01)the acute nicotine grp(p>.01)Stimulation of ST 36 just Stimulation of ST 36 just before nicotine challenge, as before nicotine challenge, as well as during the 3 day w/d well as during the 3 day w/d period, completely blocked the period, completely blocked the effects of nicotine on effects of nicotine on locomotor activity duringthe 60 locomotor activity duringthe 60 minute test period versus minute test period versus control (p>.05)control (p>.05)

ResultsResults

Fos-like immunoreactivity (FLI) measurement found the Fos-like immunoreactivity (FLI) measurement found the a massive amt of FLI was present in the nucleus a massive amt of FLI was present in the nucleus accumbans and striatum of repeat nicotine tx-d grp vs. accumbans and striatum of repeat nicotine tx-d grp vs. the acute nicotine tx’d grpthe acute nicotine tx’d grpRepeat nicotine grp had sig’ly increase FLI in the shell of Repeat nicotine grp had sig’ly increase FLI in the shell of the NA but not in the corethe NA but not in the coreAC at ST 36 significantly decreased FLI in the shell and AC at ST 36 significantly decreased FLI in the shell and the core compared to controls during subsequent the core compared to controls during subsequent nicotine challengenicotine challengeRepeat nicotine significantly increased the FLI compared Repeat nicotine significantly increased the FLI compared to acute nicotine tx in the DL and VM stiatumto acute nicotine tx in the DL and VM stiatumAC at ST 36, HT 7, or LU 9 significantly decreased FLI AC at ST 36, HT 7, or LU 9 significantly decreased FLI compared to control in the VM but not DL striatumcompared to control in the VM but not DL striatum

Acupuncture & Nitric OxideAcupuncture & Nitric Oxide

NO is one of the most important messenger NO is one of the most important messenger molecules and has been shown to function much molecules and has been shown to function much like a neurotransmitter with widespread signaling like a neurotransmitter with widespread signaling and functionand functionNO stimulates NE release from the central and NO stimulates NE release from the central and peripheral nervous system which can increase peripheral nervous system which can increase sympathetic nervous system activitysympathetic nervous system activityNO in the gracile nucleus has been shown to NO in the gracile nucleus has been shown to mediate acupuncture signals through the dorsal mediate acupuncture signals through the dorsal medulla thalamic pathways in ratsmedulla thalamic pathways in rats

NO and AcupunctureNO and Acupuncture

Recent studies by Ma et al showed EA stimulation of ST Recent studies by Ma et al showed EA stimulation of ST 36 in rats induces an upregulation of neuronal NO 36 in rats induces an upregulation of neuronal NO synthase/ NADPH diaphorase expression in the gracile synthase/ NADPH diaphorase expression in the gracile nucleus in the spinal chordnucleus in the spinal chordFurther study by Ma 2003, showed that the skin Further study by Ma 2003, showed that the skin underlying real acupuncture points has higher NO and underlying real acupuncture points has higher NO and nNOS expression than non-points when given EA in ratsnNOS expression than non-points when given EA in ratsHowever, EA-induced nNOS expressions may vary in However, EA-induced nNOS expressions may vary in different parts of the braindifferent parts of the brainJang et al (2003) showed that nNOS expression was Jang et al (2003) showed that nNOS expression was increased in the peri-aqueductal grey in rats with increased in the peri-aqueductal grey in rats with strepozotocin induced diabetes and that EA of ST 36 strepozotocin induced diabetes and that EA of ST 36 suppressed this DM enhancement of nNOSsuppressed this DM enhancement of nNOS

Acupuncture for Tx MA Detox: NO Acupuncture for Tx MA Detox: NO MechanismsMechanisms

Purpose is to examine the effect of acupuncture on the Purpose is to examine the effect of acupuncture on the symptoms of MA withdrawal and to evaluate any related symptoms of MA withdrawal and to evaluate any related NO changesNO changesPrimary hypothesis is that AC increases skin NO, serum Primary hypothesis is that AC increases skin NO, serum nitrate, nitrite, NE during MA withdrawalnitrate, nitrite, NE during MA withdrawalMA use depletes CNS neurons of dopamine, NE, and MA use depletes CNS neurons of dopamine, NE, and epinephrine thru hyperthermia and hyper-excitationepinephrine thru hyperthermia and hyper-excitationThis depletion leads to characteristic MA withdrawal sx This depletion leads to characteristic MA withdrawal sx of irritability, apathy, difficulty sleeping, fatigue, and of irritability, apathy, difficulty sleeping, fatigue, and decreased mood.decreased mood.Acupuncture, through raising NO and central nNOS, will Acupuncture, through raising NO and central nNOS, will increase NE and epinephrine, and correct for the deficit, increase NE and epinephrine, and correct for the deficit, yielding sx improvementyielding sx improvement

Acupuncture ProtocolAcupuncture Protocol

Single blind design: N=20 MA dependent subjects who Single blind design: N=20 MA dependent subjects who are treatment seeking outpatientsare treatment seeking outpatientsRandom assignment to rcv AC or sham ACRandom assignment to rcv AC or sham ACBoth groups rcv individual MI 2x/wk & grp therapy Both groups rcv individual MI 2x/wk & grp therapy 1X/week1X/weekCounseling not mandatory but encouragedCounseling not mandatory but encouragedBoth groups will receive AC tx 4X/week 1, 3X/week 2, Both groups will receive AC tx 4X/week 1, 3X/week 2, and 2X/week 3and 2X/week 3Both grps will rcv AC before counseling and will rcv tx Both grps will rcv AC before counseling and will rcv tx alone, on a treatment table, with a monitor and the alone, on a treatment table, with a monitor and the acupuncturist presentacupuncturist presentBoth treatments will leave needles in for 45 minutesBoth treatments will leave needles in for 45 minutes

Acupuncture ProtocolAcupuncture Protocol

AC grp: AC grp: – Bilateral EA of NADA points in the auricle with Bilateral EA of NADA points in the auricle with

needles then placedneedles then placed– 4 Gates: 4 needles on body: LI 4 and LR 34 Gates: 4 needles on body: LI 4 and LR 3– EA at St 36 for 20 secondsEA at St 36 for 20 seconds

Sham AC grp:Sham AC grp:– Sham EA of non points on the ear with needles Sham EA of non points on the ear with needles

placed on non pointsplaced on non points– 4 Non-points placed near to real points4 Non-points placed near to real points– Sham EA at non-point near ST 36 for 20 secondsSham EA at non-point near ST 36 for 20 seconds

MeasurementsMeasurements

Collecting BAI and BDI before and after tx on Collecting BAI and BDI before and after tx on day 1,3,7, and 14day 1,3,7, and 14

Serum nitrate, nitrite before tx on day 1 and after Serum nitrate, nitrite before tx on day 1 and after tx on days 7 and 14tx on days 7 and 14

Skin NO before, during, and after tx on days 1 Skin NO before, during, and after tx on days 1 and 14 at ST 36 or non pointand 14 at ST 36 or non point

UTS at every visitUTS at every visit

Tx retention as outcomeTx retention as outcome

At 60 and 90 days post-tx, subj U/A and ASIAt 60 and 90 days post-tx, subj U/A and ASI

Protocol RationaleProtocol Rationale

MA difficult addiction to txMA difficult addiction to tx1 study in literature mentioned AC was non-effective1 study in literature mentioned AC was non-effectiveUnclear if this is due to the mechanism of MA or under-tx with ACUnclear if this is due to the mechanism of MA or under-tx with ACUsing fairly high dose AC (more potent, but freq normal), as NADA Using fairly high dose AC (more potent, but freq normal), as NADA protocol non-specificprotocol non-specificAC is a somatic tx and psychosocial intervention has been shown to AC is a somatic tx and psychosocial intervention has been shown to be necessary for AC to be beneficialbe necessary for AC to be beneficialAC alone is not INTEGRATIVE medicine & it is not a substitute for AC alone is not INTEGRATIVE medicine & it is not a substitute for psychosocial treatment, only a supportpsychosocial treatment, only a supportPoint protocols have no place in TCM and individual txs and Point protocols have no place in TCM and individual txs and imbalances are unique. Therefore, if AC does not yield positive imbalances are unique. Therefore, if AC does not yield positive scientific results, it DOES NOT mean that AC is ineffectivescientific results, it DOES NOT mean that AC is ineffective