Transcript document

Acupuncture & Addiction
By Shahla Modir, MD
Addiction Medicine
UCLA Neuropsychiatric
Institute
History of Acupuncture
Traditional Chinese
Medicine
dates back 2500
years
4 components:
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Acupuncture
Herbal medicine
Tui Na
Qi gong
Chinese Medicine Theory
Non-linear/Non-reductionist paradigm
A part can only be understood in relation
to the whole: dialectical logic
TCM is based on Yin & Yang theory
– Uses the constructs of the 2 polar
complements
– Neither forces nor material entities
Identify how things function in relationship to each
other
Yin
Represents the element of water
Associated with cold, rest, passivity,
shade, tranquil, downward, decrease,
quiescence
The end, completion and fruition
Present in the body and fluids, but also in
the natural environment
Yang
Represents the element of fire
Associated with bright, heat, stimulation,
movement, excitement, vigor, light, up,
outward, increase
It is arousal, beginning, and dynamic
potential
Present in the body and in the natural
environment
Yin and Yang Theory
Examples of Yin & Yang
– Night/Day, Earth/Heaven, Fall & Winter/ Spring &
Summer, Male/Female, Cold/Hot
– Acceptance & Responsiveness/Desire &Willfulness
Yin and Yang control each other: if Yin is in
excess, yang will be too weak
Yin and Yang transform into each other
– Harmonious change as a natural cause of events
– Sudden rupture and transformation of extremely
disharmonious situations
Yin and Yang
Balanced Health
People are constantly bombarded in the natural universe with
changes in Yin and Yang:
– daily cycles, seasonal changes, food and lifestyle choices
– all affect the organisms balance of yin/yang
When the amount of Yin and Yang are relatively balanced
– a state of health and equanimity
When there are unequal portions of Yin and Yang in the system
– leads to disharmony in the body and mind and symptoms or correlates
of disease
Extreme disharmony means that the deficiency of one aspect can
not continue to support the excess of the other aspect
– Extreme high fever leading to shock and hypothermia
– Relationship of an extreme passive person with an aggressive person
Macrocosmic Qi
Fundamental to TCM and Chinese culture, but
difficult to capture the meaning
All in the universe that is organic, inorganic is
defined by its qi
– Mountains, plants, human emotion
– Vital energy, a kind of matter on the verge of
becoming energy
– The thread connecting all beings, the potential of and
actualization of transformation
– Does not cause change but is present before, during ,
and after
Microcosmic Qi
Qi in an applied practical setting of the
human organism
– Means the dynamic of engendering
movement, tension, activation (yang aspect)
3 sources of Qi
– Original Qi: (Yuan qi) inherited or ancestral qi
– Grain Qi: (Gu-qi) derived from food
– Natural Qi: (Kong qi) extracted by lungs from
the air
Qi in the body
5 functions of Qi
– Source of all
movement &
accompanies it
– Protects the body
– Source of harmonious
transformations
– Ensures stability and
governs retention
– Warms the body
5 primary types of Qi
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Organ qi
Meridian qi
Nutritive qi
Protective qi
Ancenstral qi
Meridians (Jing-luo)
Jing meaning to go through or thread in a fabric
Luo meaning something that connects or attaches
Meridians are the 12 pathways that carry qi and blood
through the body; they are not blood vessels or nerves
A subtle energetic lattice that links together the
fundamental textures to the organs and unifies all parts
of the body
Essential for harmonious flow to occur in order to
regulate the flow of the yin and yang, move qi and blood,
moisten the tendons and bones, and benefit the joints
Imbalanced (too much or too little) yin or yang in the
flow, blocked flow, insufficient/excess qi all create
disharmony and disease
Acupuncture
The Meridian system
12 regular meridians that correspond to each of
the 5 Yin and 6 Yang organs and to the
Pericardium
Insertion of very fine needles into points
along the meridian can rebalance the
bodies disharmonies
Auricular Acupuncture
Auricular acupuncture is a variant
assumes that the body is like a holograph and
is represented entirely on the ear.
the map was created based on the experience
of 50,000 soldiers in the Nan Jing army
the needles are inserted 1-3 millmeters and
withdrawn
Auricular Acupuncture
Landmark Studies
Neuronal specificity of
acupuncture response:
an fMRI study with EA
– Study of 15 healthy
volunteers using mock EA
(no EA), minimal EA at real
acupoints used for
analgesia, sham EA (real
EA at non-meridian points
– The limbic system showed
significant modulation by
EA at analgesic acupoints
rather than non-meridian
points
Correlation between
acupoints and
corresponding brain
cortices on fMRI
– 12 healthy volunteers
stimulated visual acupoints
– Found correlations
between the activation of
specific visual cortex and
the corresponding acupoint
stimulation predicted by the
acupuncture literature
Acupuncture and Addiction
Chinese neurosurgeon HL Wen in 1972
discovered benefits on accident
– Noticed that acupuncture pain treatments in postsurgical, opiate addicted patients seemed to alleviate
withdrawal
– Used EA of lung point in 40 patients with opiate
addiction found uniform decreases in opiate
withdrawal symptoms
Pomeranz et al found EA in rats significantly
reduced the signs of morphine withdrawal
– Supports work of Ng, Thoa, and Albert that showed
auricular EA significantly reduced signs of naloxoneinduced withdrawal in morphine dependent rats
NADA protocol
Michael Smith, a psychiatrist in the Bronx, N,
modified Wen’s protocol by eliminating the EA
and abbreviating the prescription to five
auricular needles
This prescription was not designed for
withdrawal from any particular drug
Instead designed to reduce anxiety, craving, and
dysphoria during the early weeks of withdrawal
Meant to make acupuncture more accessible
and affordable
NADA protocol
National Acupuncture
Detoxification Association
800 treatment centers
use this protocol
Many studies use some
variant of the protocol
which states 3-5 points
should be used
Uses 5 points in bilateral
auricles left in place for
40 minutes and removed
Points:
Shen Men
Sympathetic
Lung
Liver
Kidney
Acupuncture Study Design
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2.
3.
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Problems with designing acupuncture studies
Single blinded
Control points are usually active “unrelated”
points
No inert treatments in TCM model; paradigm
mismatch
Ulett (1992) from Western perspective argued
auricular acupuncture effect due to stimulation
of the vagus nerve that innervates the entire
concha & thus needles anywhere on the
concha will produce an effect
Opiate detoxification
Washburn, Keenan, and Nazareno (1990)
reported on study 100 subjects with opiate
dependence randomly assigned to receive
acupuncture or sham acupuncture
Outpatient, 21 day detox program
Exp’tl subjects showed significantly better
attendance and remained in treatment for longer
periods than controls
However only 7% of exp’tal grp and 4% of the
placebo group tested negative for opiates after 2
weeks
Opiate detoxification
Clark (1990)
N=84 opiate dependent
chose either methadone
or acupuncture
Methadone was gradual
decrease over 21 days
42 pairs subjects
matched age, race, and
sex
Results
At 90 day f/u:
– 31% acupuncture subj
drug free/ 53% pos
U/A
– 14% methadone subj
drug free/ 62% pos
U/A
Opiate Detoxification
Greiger 1987
65 incarcerated
opiate dependents
Randomly assigned
– Methadone detox with
acupuncture
– Methadone detox
without acupuncture
Results:
Methadone with
acupuncture reported
significantly less
withdrawal symtoms
(stomach cramps,
diarrhea, h/a,
depression)
No placebo arm of the
study
Alcohol detoxification
Two placebo-design
studies
– Bullock (1987) studied 54
chronic alcohol abusers
and randomly assigned to
receive acupoints or near
by acupoints (non detox
oriented)
Inpatient setting, free to
leave each day, alcohol
consumption not excluded
2 ½ months of treatment
Results
– Throughout study
experimental subjects
showed better attendance
and decreased self report
need for alcohol
– After 2nd week of tx, exp’tal
group reported decreased
number of drinking
episodes, decreased
number of subjects
admitted to a local detox
unit for alcohol tx
Alcohol detoxification
Bullock et al (1987)
replicated using a
larger sample
N=80 with subject
interviews at 1,3, and
6 months post
treatment
2 months of treatment
Results
– Acupuncture group
showed greater
retention in treatment
– During the 1,3, and 6
month f/u interviews,
exp’tal subjects
expressed
Less need for alcohol
Less self reported
drinking episodes
Greater self reported
abstinence
Cocaine detoxification
Lipton, Brewington, and Smith
(1990) conducted a placebo
designed study
– 150 cocaine/crack abusers
entering a substance abuse
program
– randomly assigned to receive
auricular acupuncture at
correct sites or nearby points
not related to detoxification
– Treatments provided for 1
month and urine tox were
provided after each session
– Interviews at 30 and 90 days
after treatment were
conducted
Results
– Self report measures and U/A
profiles showed a significant
tendency with both groups
toward decreased cocaine
consumption
– Pre-tx cocaine/crack usage
ave at 20 days/month with all
subjects. During tx period and
at 3 mos post tx self report
use was reduced to 5
days/month with both grps
– Tx retention throughout the
experiment did not differ
– U/A profiles indicated superior
outcomes with the exp’tl grp
during tx & showed more
cocaine negative urines over
the course of tx (24% vs 21).
Further results
Subjects in the study did not routinely get
counseling. Each morning, the clinic accepted
into tx the first 3 people and they were put in
therapy and acupuncture. Later walk ins
received acupuncture alone.
Urine profiles of the 73 subjs who received
correct site acupuncture were compared with 42
clinic pts who received counseling and
acupuncture
Results showed drop out/retention rates were
the same but 50% of counseling/acu pts had neg
cocaine urines vs. 24% for acu only pts
Cocaine Addiction
Margolin 2000
82 cocaine dependent, methadone maintained
patients/ oupt program
Random assignment
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Auricular acupuncture 4 points
Auricular control 4 points
Relaxation control: videos and relaxation training
5x/ week for 8 weeks
No financial incentive
40 min of each tx, after methadone dose
Results
Patients assigned to acupuncture group
significantly more likely to provide
cocaine negative urines compared to
both the needle control and relaxation
training.
– P=.01
– odds ratio 3.41
– confidence interval 1.33-8.72
Cocaine/Opiate Addiction
Margolin (2002)
RCT single blind/ outpatient study
6 community based clinics :
– 3 hospital affiliated/3 methadone maintenance
N=620 Adults, ave. age= 38.8
412=cocaine only 208=opiate & cocaine
Cocaine and Opiate
Random assignment to 3 arms
– Auricular acupuncture = 222
– Needle control auricular = 203
– Relaxation training = 195
– Treatments 5X/week for 8 weeks
– Paid 2$/session and 10$/week
– Drug counseling “N.A.” provided not required
Results
Intent to tx analysis of U/A showed decreased
cocaine use in all 3 groups p=.002
No between group differences
No differences in treatment retention 44%-46%
for 8 weeks
Counseling ie, NA was poorly attended for all
Authors state that a model of just acupuncture
without more intensive psychosocial tx led to
poor outcome; subj population also very difficult
Methamphetamine and
Acupuncture
No single study reports in the literature
Only one found uses data collected on patients
with chronic arrest history and drug abuse: nonrandomized, no placebo acupuncture
37 patients received acupuncture during early
weeks of tx and were followed for 180 days post
admission
These data were compared to archived
information from 49 no acupuncture patients
who entered tx the 5 mos before it was available
Total of 86 subjects completed: MA drug of
choice for 44/86 subjects
Protocol
Acupuncture protocol:
– NADA auricular protocol daily for 3 weeks
then M,W,F for 4 weeks, then M, T for 2
weeks
– During tx, no talking, sitting in recline chairs
with soft music for 45 minutes
Non-AC protocol: Tx as usual
Results
AC patients significantly
higher program retention
than NA patients at day #:
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30 (p>0.0001)
60 (p>.002),
90 (p>.001),
120 (p>.007),
150 (p>.031)
At 180 days a higher %
AC than NA pts remained
in tx, not significant
In AC pts: decreased # of
new arrests, drug positive
U/A, but not significant
Regardless of tx condition
– MA pts had lower program
retention overall
– AC improved the retention
only up to 30 days (p>.021)
Does AC not work in this
population or is more tx
rqr’d?
Acupuncture Mechanism
Clement-Jones et al (1979)
Examined EOP levels in 5 grps of subjs
– 6 heroin dep with mild withdrawal who rcv’d EA and
gave bld and CSF
– 6 heroin dep with severe withdrawal; No EA but gave
bld
– 7 hospitalized pts (unspecified conditions) –provided
CSf
– 25 healthy volunteers; gave blood
– 18 hospitalized pts with non-endocrine dz; gave blood
Results
Heroin dep subj basal B-endorphin levels higher
in both blood and CSF vs. non-addicted pts
Addicted subj’s bld and CSF B-endorphin levels
not change significantly with EA
Basal met-enkephalin level of heroin addicted
pts not differ from non-addicted
EA tx of heroin addicts led to rise in CSF met
enkephalin level but no change in blood metenkephalin levels
Acupuncture Mechanism
Wen et al 1978a
8 heroin dependent females undergoing
detox
6 non-abusing controls
Measured blood levels of: ACTH, cortisol,
c-AMP and urine aldosterone,
catecholamines, VMA, cortisol, and cAMP
Design
Heroin abusing subjects received
methadone decreasing over 10 day period
(30 mg-10 mg)
On days 4-10 no additional medication
given, but subj received EA 3x/day
Non-abusing controls received EA on days
4-10 3x/day
Results
Heroin addicted subjects showed
significant reduction post EA in plasma
cortisol, ACTH, c-AMP
Normal control subjects post EA showed
decreased ACTH, cortisol
Previous research has shown that heroin
abusing subjects in withdrawal normally
have increased plasma cortisol-not
decreased
Acupuncture Mechanism
Wen et al 1978b
Replicated study
N=40 heroin dep subjs/ N=31 non-dependant
Measured changes in cortisol, ACTH, c-AMP pre
versus post EA
Found significant decrease in cortisol/ACTH
levels post EA in heroin dep subj during detox
No changes were found in the non-dependent
controls post EA
Acupuncture Mechanism: c-Fos
Purpose of the study to evaluate whether AC
could affect the fxn’al alterations of the mesolimbic dopaminergic system involved in the
nicotine –induced behavioral sensitization in rats
and if AC would decrease the expected increase
in nicotine-induced locomotor activity
35 male rats randomly divided 8 days prior to
procedure
Repeat nicotine grps were pre-tx’ed with nicotine
2x/day X 7 days and then were systemically
challenged with nicotine on day 11
Drugs were not injected on days 8-10
Protocol
The saline tx’d grp rcv’d saline for 7 days
and was challenged with saline
The expt’al grp rcv’d acupuncture at St 36,
HT 7, or LU 9 during the withdrawal period
The control grp did not rcv any tx other
than a slight grab during the withdrawal
All groups were challenged with systemic
nicotine at day 11
Results
Behavioral analysis: rats given
repeat nicotine showed
increased beh response when
given nicotine challenge
compared to saline rats
During the nicotine w/d period,
AC at ST 36 , but not the other
AC points attenuated the
expected increase in nicotine
induced locomotor activity to
subsequent nicotine
challenges
Beh response to the nicotine
challenge in the repeat
nicotine grp was higher than in
the acute nicotine grp(p>.01)
Stimulation of ST 36 just
before nicotine challenge, as
well as during the 3 day w/d
period, completely blocked the
effects of nicotine on locomotor
activity duringthe 60 minute
test period versus control
(p>.05)
Results
Fos-like immunoreactivity (FLI) measurement found the
a massive amt of FLI was present in the nucleus
accumbans and striatum of repeat nicotine tx-d grp vs.
the acute nicotine tx’d grp
Repeat nicotine grp had sig’ly increase FLI in the shell of
the NA but not in the core
AC at ST 36 significantly decreased FLI in the shell and
the core compared to controls during subsequent
nicotine challenge
Repeat nicotine significantly increased the FLI compared
to acute nicotine tx in the DL and VM stiatum
AC at ST 36, HT 7, or LU 9 significantly decreased FLI
compared to control in the VM but not DL striatum
Acupuncture & Nitric Oxide
NO is one of the most important messenger
molecules and has been shown to function
much like a neurotransmitter with widespread
signaling and function
NO stimulates NE release from the central and
peripheral nervous system which can increase
sympathetic nervous system activity
NO in the gracile nucleus has been shown to
mediate acupuncture signals through the dorsal
medulla thalamic pathways in rats
NO and Acupuncture
Recent studies by Ma et al showed EA stimulation of ST
36 in rats induces an upregulation of neuronal NO
synthase/ NADPH diaphorase expression in the gracile
nucleus in the spinal chord
Further study by Ma 2003, showed that the skin
underlying real acupuncture points has higher NO and
nNOS expression than non-points when given EA in rats
However, EA-induced nNOS expressions may vary in
different parts of the brain
Jang et al (2003) showed that nNOS expression was
increased in the peri-aqueductal grey in rats with
strepozotocin induced diabetes and that EA of ST 36
suppressed this DM enhancement of nNOS
Acupuncture for Tx MA Detox: NO
Mechanisms
Purpose is to examine the effect of acupuncture on the
symptoms of MA withdrawal and to evaluate any related
NO changes
Primary hypothesis is that AC increases skin NO, serum
nitrate, nitrite, NE during MA withdrawal
MA use depletes CNS neurons of dopamine, NE, and
epinephrine thru hyperthermia and hyper-excitation
This depletion leads to characteristic MA withdrawal sx
of irritability, apathy, difficulty sleeping, fatigue, and
decreased mood.
Acupuncture, through raising NO and central nNOS, will
increase NE and epinephrine, and correct for the deficit,
yielding sx improvement
Acupuncture Protocol
Single blind design: N=20 MA dependent subjects who
are treatment seeking outpatients
Random assignment to rcv AC or sham AC
Both groups rcv individual MI 2x/wk & grp therapy
1X/week
Counseling not mandatory but encouraged
Both groups will receive AC tx 4X/week 1, 3X/week 2,
and 2X/week 3
Both grps will rcv AC before counseling and will rcv tx
alone, on a treatment table, with a monitor and the
acupuncturist present
Both treatments will leave needles in for 45 minutes
Acupuncture Protocol
AC grp:
– Bilateral EA of NADA points in the auricle with
needles then placed
– 4 Gates: 4 needles on body: LI 4 and LR 3
– EA at St 36 for 20 seconds
Sham AC grp:
– Sham EA of non points on the ear with needles
placed on non points
– 4 Non-points placed near to real points
– Sham EA at non-point near ST 36 for 20 seconds
Measurements
Collecting BAI and BDI before and after tx on
day 1,3,7, and 14
Serum nitrate, nitrite before tx on day 1 and after
tx on days 7 and 14
Skin NO before, during, and after tx on days 1
and 14 at ST 36 or non point
UTS at every visit
Tx retention as outcome
At 60 and 90 days post-tx, subj U/A and ASI
Protocol Rationale
MA difficult addiction to tx
1 study in literature mentioned AC was non-effective
Unclear if this is due to the mechanism of MA or under-tx with AC
Using fairly high dose AC (more potent, but freq normal), as NADA
protocol non-specific
AC is a somatic tx and psychosocial intervention has been shown to
be necessary for AC to be beneficial
AC alone is not INTEGRATIVE medicine & it is not a substitute for
psychosocial treatment, only a support
Point protocols have no place in TCM and individual txs and
imbalances are unique. Therefore, if AC does not yield positive
scientific results, it DOES NOT mean that AC is ineffective