AURICULAR ACUPUNCTURE IN ALCOHOL TREATMENT
Michael O. Smith, Patricia Culliton, Claudia Voyles
Acupuncture is currently used in the treatment of addiction by approximately 2000 treatment program worldwide. Clinical evidence supports that auricular acupuncture is effective in ameliorating acute and long-term withdrawal and craving symptoms associated with alcohol addiction. Treatment programs use acupuncture as a foundation for later psychosocial recovery.
It is a nonverbal, nonthreatening, first-step intervention that has an immediate calming effect on patients. Initial participation in a program with acupuncture has been found to improve patients' overall treatment retention and to facilitate their subsequent involvement in the therapeutic process. This chapter describes the practical use and research findings relating to acupuncture for alcohol treatment. Trained clinicians needle three to five ear acupuncture points in patients who are seated for 40 to 45 minutes in a large group room. This method facilitates the convenient treatment of a substantial number of patients to be at the same time. Acupuncture is integrated with conventional elements of psychosocial rehabilitation. Other core concepts reflected in many acupuncture-based programs include a supportive, nonconfrontational approach to counseling; emphasis on participation in an AA program early in the treatment process; reduced need to screen for "appropriate" patients; use of herbal "sleep mix"; willingness to work with court-related agencies and other agencies; and a tolerant, informal, family-like atmosphere. As a safe, cost-efficient and effective adjunctive procedure, acupuncture has gained increasing acceptance from agencies that are responsible for overseeing alcohol treatment. The federal Center for Substance Abuse Treatment (CSAT) has held two consensus conferences that will result in publication in 2003 of a treatment improvement protocol on the integration of acupuncture in addiction treatment
Alcohol treatment clinicians can easily and effectively learn the protocol in a 70-hour training program that emphasizes clinical apprenticeship. Each acupuncture detoxification specialist (ADS) can provide about 20 treatments per hour in a group setting under the general supervision of a licensed acupuncturist or other health professional, qualified according to local regulations. This arrangement allows acupuncture to be integrated with existing services in a flexible and cost-effective manner, increasing access and improving clinical relationships within the treatment milieu. Programs that address alcoholism along the continuum of care may successfully integrate acupuncture. Characteristically, acupuncture proves a very valuable tool for treating special populations, including criminal justice-involved patients, women, adolescents, and patients with concomitant mental disorders. Acupuncture is a major component of the ancient tradition of Chinese medicine. Acupuncture was used by numerous 19th century U.S. practitioners, including Sir William Osier. In the early 1970s, American interest was renewed when relations with China were reopened. In the United States, most states have acupuncture licensing laws, many of which include exemptions allowing clinical staff with proper training in addiction treatment to provide a limited acupuncture protocol. Acupuncture consists of stimulation of specified locations on the surface of the body, which alters and improves bodily function. Acupuncture points are physiologically distinct from the immediate environment; they have less electrical resistance and, therefore, greater electrical conductivity. The points are warmer than the surrounding area by 0.1 to 0.2 fractions of a degree.
Needling is the most convenient and efficient means of stimulating acupuncture points. Acupuncture needles are stainless steel shafts of varying lengths and thicknesses. Acupuncture needles are provided in convenient sterile packages. Most Western facilities use the needles once and discard them, although needles may be cleaned, sterilized, and reused as is the case with surgical equipment.
Needles are inserted with a brief but steady movement. The procedure is nearly painless and causes rapid onset of a gratifying sense of relaxation. On first exposure, most patients express fear of the pain of needle insertion and are confused by the idea that little needles can cope with their big problems. This fear is easily overcome by letting prospective patients observe the actual treatment Process.
Patients may notice local paresthesia effects such as warmth and tingling. Patients may feel quite sleepy after each of the first several treatments. This reaction is part of the quiet recovery process and passes readily. Rarely in alcohol treatment, patients experience a "needling reaction" of syncope, which resolves when the needles are removed
EARLY DEVELOPMENT OF ACUPUNCTURE USE FOR SUBSTANCE ABUSE
Acupuncture treatment for drug and alcohol problems was primarily developed at Lincoln Hospital, a city-owned facility in the impoverished South Bronx. The Lincoln Recovery Center is a state-licensed treatment program, which has provided more than 500,000 acupuncture treatments in the past 28 years. Dr. Yoshiaki Omura was the consultant who began the program in 1974, initially applying electrical stimulation to the lung point in the ear for opiate detoxification. Patients reported less malaise and better relaxation in symptom surveys. Reduction in opiate withdrawal symptoms and prolonged program retention were noted with twice daily treatments. Gradually, the ear acupuncture protocol was expanded by adding the "shen men" spirit gate), a point which is well known for producing relaxation. During a developmental process that extended over several years, other ear points were tried on the basis of lower resistance, decreased pain sensitivity, and clinical indication. Electric < stimulation was discontinued. Dr. Michael Smith of Lincoln added the "sympathetic," "kidney," and "liver" points to create a basic five point formula. Traditional Chinese theory associates the lung with the grieving process; the liver with resolving aggression; and the kidney with will power and rebirth. From the point of view of Chinese theory, using a single basic formula for such generally depleted patients is appropriate. In traditional Chinese medicine, the lack of a clam inner tone in a person is described as a condition of "empty fire" (xu huo), because the "heat" of excess symptoms burns out of control when the calm inner tone is lost It is easy to be confused by the "empty fire" that many alcoholics exhibit and to conclude that the main goal should be the sedation of excess symptoms. Alcoholics themselves use this approach by choosing to drink. Acupuncture helps patients with this condition to restore inner control. It is a supportive rather than a suppressive process
CONTROLLED RESEARCH
H. L. Wen of Hong Kong was the first physician to report successful treatment of addiction withdrawal symptoms. He observed that opium addicts who received electro-acupuncture as postsurgical
Analgesia experienced relief of withdrawal symptoms. A number of controlled studies have been conducted since, using various modified versions of the National Acupuncture Detoxification Association (NADA) ear point formula. Two placebo-design studies provide strong support for use of acupuncture as a treatment for alcoholics. One research team studied 54 chronic alcohol abusers randomly assigned to receive acupuncture either at NADA ear points or at nearby point locations not specifically related to alcohol. Subjects were treated in an inpatient setting but were free to leave the program each day. Throughout the study, experimental subjects showed significantly better outcomes regarding their attendance and their self-reported need for alcohol. Significant differences favoring the experimental group were also found regarding: (1) number of self-reported drinking episodes, (2) self-reports of effectiveness of acupuncture in removing the desire to drink, and (3) number of subjects admitted to a local detoxification unit for alcohol-related treatment. These findings were later replicated by the same authors who used a larger (n = 80) sample over a longer (6-month) follow-up period. In the treatment group, 21 of 40 patients completed the 8-week treatment period compared with 1 of 40 controls. Significant differences favoring the experimental group were again noted. Researchers found a 52% retention rate for the experimental group of alcoholism patients compared with 2% for placebo patients. Placebo subjects self-reported more than twice the number of drinking episodes reported by experimental subjects. The number of experimental subjects was less than half that of the placebo subjects who were readmitted to the local hospital alcohol detoxification unit during the follow-up period.
Ear acupuncture charts indicate that all areas on the anterior surface of the ear are identified as active treatment locations. Use of a "placebo" or "sham" acupuncture technique is actually an effort to use relatively ineffective points in contrast to the conventional use of totally ineffective sugar pills in pharmaceutical trials. Sham points are usually located on the external helix or rim of the ear, although there is no consensus about the level of effectiveness of this procedure. The alcoholism studies described earlier used subjects highly prone to failure; therefore, they may have achieved a more ineffective demonstration of the difference between active and sham points.
These same authors purported to replicate their earlier studies in a recent trial. In this study, they found no statistically significant differences between groups receiving conventional treatment and various acupuncture groups, although the subjects reported decreased desire for alcohol. The 2002 study differs from the 1989 study in significant ways: (1) the average number of acupuncture treatments in the more recent study was 38% of the number of treatments given to the full-retention group in the previous study (10 rather than 26); and (2) acupuncture was embedded as a voluntary component in ah extensive, mandatory, psychosocial protocol in the more recent study, whereas attendance at only two AA meetings per week of was required in the previous study. Each of these differences would be likely to reduce the potential impact of acupuncture in the recent study
CLINICAL APPLICATIONS
Acupuncture detoxification programs report substantial reduction in recidivism rates. The Hooper Foundation (a public detox facility in Portland, Oregon) cited a decrease in recidivism from 25% to 6% in comparison with the rate in the previous year, when acupuncture was not used. The Kent-Sussex Detoxification Center (a state-run facility in Ellendale, Delaware) reported a decrease in recidivism from 87% to 18%.
The Substance Abuse Recovery program (Flint, Michigan) noted that 83% of a group of 100 General Motors employees were drug-free and alcohol-free a year after entering an acupuncture-based treatment program. Most of these patients had reported prior attempts at treatment and frequent relapses. All of the subjects in the 17% failure group had made fewer than five program visits. Seventy-four percent of the success group continued to attend AA and NADA meetings after completing the treatment program. Treatment protocols specifically designed for adolescents, such as those of the Alcohol Treatment Center in Chicago and a Job Corps-related program in Brooklyn, have shown retention rates comparable with those of adult programs.
Directors of the acupuncture social setting of the detoxification program conducted by the Tulalip Tribe at Marysville, Washington estimate a yearly saving of $148,000 resulting from fewer referrals to hospital programs. Inpatient alcohol detoxification units typically combine acupuncture and herbal sleep mix with a tapering benzodiazepine protocol. Patients report few symptoms and better sleep. Vital signs of these patients indicate stability and hence a much lower use of benzodiazepines. One residential program in Connecticut noted a 90% decrease in use of Valium over several years' time when only herbal "sleep mix" was added to the protocol.
Retention of alcohol detoxification patients at the Hooper Foundation increased by 50% when acupuncture was added their program in 1988. Some alcoholics who receive acupuncture actually report
an aversion to alcohol. The Woodhull Hospital in Brooklyn reported that 94% of the patients in the acupuncture supplement group remained abstinent compared with 43% of the control group who received only conventional outpatient services. In general, acupuncture-based programs report improved engagement and retention of patients, a decreased number of discharges against medical/program advice (American Medical Association/American Psychiatric Association), increased completion rates, and improved client indicators of health and well-being.
Acupuncture treatment is generally made available to patients 5 to 6 days per week. Morning treatment hours seem to be more beneficial. Active patients receive treatment three to six times per week. The duration of acupuncture treatment depends on many factors. Inpatient programs should stress the use of acupuncture at the beginning of treatment for detoxification and stabilization and before discharge to alleviate separation anxiety. Outpatients typically receive acupuncture on an active basis for 1 to 3 months. About 10% of these outpatients choose to take acupuncture for more than 1 year if possible. Acupuncture is not primarily a "dose"-related phenomenon as is pharmaceutical treatment. Acupuncture more appropriately represents a qualitative service comparable to a school class or psychotherapy session. Acupuncture offers a support for relapse prevention. Relapsing patients are often able to continue to be involved in acupuncture even if they are no longer constructive participants in psychotherapy.
A wide range of patients can be accepted for the initial stage of treatment because there is no verbal motivational requirement. In addition, acupuncture is effective for a wide range of psychological states. Ambivalent streetwise patients find the acupuncture setting almost impossible to manipulate. The setting is so soothing and self-protective that even extremely antisocial people are able to fit into it. Problems relating to language and cultural differences are diminished. For new patients, frequent acupuncture treatments permit the gradual completion of assessment on a more accurate basis. Patients can be evaluated and triaged according to their ongoing response to treatment rather than merely on the basis of an interview.
The tolerant, nonverbal aspect of acupuncture facilitates retention during periods when the patient would otherwise be ambivalent, fearful, or resentful within a more intense verbal interpersonal setting. Ear acupuncture makes it easy to provide outpatient treatment on demand, without appointments, while patients are being acclimated to the interpersonal treatment setting.
Patients gradually develop respect for the values of the treatment process. Those same patients may be unable or unwilling to share their crises and failures verbally until they have time to reach more solid ground. In the acupuncture setting, time is an ally.
Acupuncture has many characteristics in common with the 12-step program (AA). It uses the group process in a tolerant, supportive, and present-time oriented manner. Participation is independent of diagnosis and level of recovery. Both approaches are simple, reinforcing, nurturing, and conveniently available. The emphasis on being responsible for oneself is common to both systems. In practice, acupuncture provides an excellent foundation for 12-step recovery. Patients seem less fearful and more receptive when they first enter the meetings. Acupuncture reduces "white-knuckle sobriety" considerably. There is less guarding and greater ability to support each other warmly. The increased ability to use 12-step meetings provides more stable support for continuing treatment on an outpatient basis and cultivating a clean and sober lifestyle
PSYCHOSOCIAL MECHANISMS OF ACTION
It is essential to understand acupuncture's psychological and social mechanisms of action to use this modality effectively. Acupuncture has an impact on the patient's thoughts and feelings that is different from that of conventional pharmaceutical treatments. Later, we discuss how the use of acupuncture has a valuable and profound impact on the dynamics of the treatment processes as a whole. We should emphasize that acupuncture for the treatment of alcoholism is provided in a group setting. The new acupuncture patient is immediately introduced to a calm and supportive group process. Patients describe acupuncture as a unique kind of balancing experience: "I was relaxed but alert." "I was able to relax without losing control." Patients who are depressed or tired say that they feel more energetic after acupuncture treatment. This encouraging and balancing group experience becomes a critically important basis for the entire alcohol treatment process.
The perception that a person can be both relaxed and alert is rather unusual in Western culture, which customarily associates relaxation with somewhat lazy or spacey behavior and alertness with a certain degree of anxiety. The relaxed and alert state is basic to the concept of health in all Asian culture. Acupuncture encourages a centering, focusing process that is typical of meditation and yoga. Therapists report that patients are "able to listen" and "remember what we tell them." Restless, impulsive behavior is greatly reduced. On the other hand, discouragement and apathy are reduced as well. It is a balancing, centering process.
One of the striking characteristics of the acupuncture treatment setting is that patients seem comfortable in their own space and in their own thinking process. One patient explained, "I sat and thought about things in a slow way, as I did when I was 10 years old." Acupuncture treatment causes the perception of various relaxing bodily processes. Patients gradually gain confidence that their minds and bodies can function in a more balanced and autonomous manner. A hopeful process is developed on a private and personal basis, laying a foundation for the development of increasing self-awareness and self-responsibility.
The nature of recovery from alcohol addiction is that patients often have quickly changing needs for crisis relief and wellness treatment. Many persons in recovery have relatively high levels of "well-ness" functioning. Even so, a crisis of craving or past association may reappear at any time. Conventional treatment settings are ill-equipped to cope with such intense and confusing behavioral swings. Often, merely the fear of a possible crisis can sabotage clinical progress. Acupuncture provides either crisis or wellness treatment using the same ear point formula- The nonverbal, present time aspects of the treatment facilitate response to a patient in any stage of crisis or denial.
Patients readily accept that it is possible to improve their acute addictive status. They seek external help to provide hospitalization and medication for withdrawal symptoms. The challenge develops when they encounter the necessity for internal change. Alcoholics perceive themselves as being unable to change from within. Their whole life revolves around powerful external change agents. Each alcoholic remembers countless examples of weakness, poor choices, and overwhelming circumstance, which lead them to the conclusion that they cannot help themselves become alcohol-free.
Acupuncture provides uniquely valuable assistance in coping with this challenge of internal redefinition. Patients often begin acupuncture treatment by seeking external escape and sedation as they do when they use drugs. When there is a rapid calming effect, they often assume there was some sort of chemical agent in the acupuncture needle. After a few treatments, they come to the astonishing conclusion that acupuncture works by revealing and employing their own capability. Regular participation in acupuncture helps patients use and revalue their internal resources much faster than is possible with conventional treatment processes. This effect contributes to the calm, cooperative atmosphere in most acupuncture settings. It reduces dropping out because of the fear of failure and low self-esteem that typify the early stage of treatment. Acupuncture creates a better atmosphere, enabling treatment staff to spend their energies on helping patients to make choices rather than be fatigued by trying to impose authority on a resistant clientele.
Acupuncture creates the foundation for psychosocial rehabilitation. At the beginning of treatment, building a proper foundation is very important. Once a foundation is established, the focus of treatment should shift away from acupuncture toward building a "house" of psychosocial recovery on that foundation.
Acupuncture is a nonverbal type of therapy. Words and verbal relationships are not necessary components of this treatment. Acupuncture is effective even when the patient lies to the therapist. With acupuncture, the verbal interaction that does take place can be quite flexible so that a patient who does not want to talk can be accommodated easily and naturally.
The most difficult-to-handle paradox in the field is the common reality that alcoholic persons usually deny that they need help. Such patients do not say anything that is helpful to the treatment process. Nevertheless, resistant patients often find themselves in a treatment setting because of referral or other pressures. Acupuncture treatment can bypass much of the verbal denial and resistance that otherwise limit retention of new and relapsed patients. Alcoholics are frequently ambivalent. Acupuncture helps therapists to reach the needy part of the psyche that wants help.
Acupuncture can reduce stress and craving so that patients gradually become more ready to participate in the treatment process.
Alcoholic patients often cannot tolerate intense interpersonal relationships. Using a conventional one-to-one approach often creates a brittle therapeutic connection. It is easily broken by events or any stress. Patients have difficulty trusting a counselor's words when they can hardly trust themselves. Even after confiding to a counselor during an intake session, a patient may feel frightened and confused about expanding that relationship. Many concerns of these patients are so complex and troublesome that talking honestly about their lives can be difficult under the best circumstances. The ambivalence typical of alcoholics makes it easy to develop misunderstandings. All of these factors support the usefulness of nonverbal technique during early and critical relapse phases of treatment and critical periods of relapse.
Acupuncture helps a program develop an underlying environment of acceptance, tolerance, and patience. There is ample space for ambivalence and temporary setbacks, which are a necessary part of any transformation. Patients can have a "quiet day" by attending the program and receiving acupuncture without having to discuss their status with a therapeutic authority figure. Since acupuncture reduces the agitated, defensive tone of the whole clinical environment, patients are able to interact with each other on a much more comfortable level. Their increased ability to listen to others and accept internal change has a profound effect on the quality and depth of communication in group therapy sessions and AA meetings. The primary community agenda can focus on the acceptance of each person and a tolerant encouragement of change rather than having to cope with defensive and antagonistic
Interactions
NATIONAL ACUPUNCTURE DETOXIFICATION ASSOCIATION MODEL
The National Acupuncture Detoxification Association (NADA) was established in 1985 to promote auricular acupuncture for addiction while maintaining quality and responsibility in the field. Lincoln Recovery Center and NADA have trained more than 10,000 ADSes in the use of the Lincoln model.
Throughout the United States, NADA-inspired programs, in addiction and criminal justice settings number close to 1000. Independent NADA training and certification programs have been established in countries around the world. Acupuncture-based treatment has widespread roots in Eastern and Western European countries as well as Australia, Saudi Arabia, Nepal, India, Trinidad, Latin America, and Burma
CONCLUSION
To really know the power of acupuncture in the treatment of alcoholism, listen to clients who have experienced it as part of their recovery transformation:
"Acupuncture has gotten me where I don't have a really manic life and I'm not depressed. I'm able to deal with everything that comes my direction because I have a lot of support also. I am energized, not miserable. I feel great about myself. I can smile today and the smile has feelings behind it. Acupuncture has hooked me up spiritually. I found my higher power—God—and He leads me each and every day."
"I was into prostitution and pornography—a violent woman … I behave differently today. I live with principles that I believe were ignited, sparked in me with acupuncture. As cumulative as acupuncture is, it has reached me on this level that I am able to change my beliefs more comfortably. I am given courage to take a look at my beliefs and empower myself, and now empower other women. I stand on the really strong truth that women can recover, and I know that acupuncture is the most valuable tool I know for recovery."
"Talking to [the counselor), getting acupuncture treatments—hate, anger, jealousy, vengefulness, vindictiveness—all that changed into compassion and love. The acupuncture treatment just helped the thought process change and the detoxing and everything."
"It has a value that if you could share with them verbally you might be able to give it to them that way, and you can't give it to them that way. You can only give it to them through the acupuncture. It somehow helped me have a way to just be with myself long enough to see what it was I needed to work on—where I was wounded, how I could heal. And it's like a nonverbal way for one person to help to give treatment to another person. It's an experiential way to help sand the rough edges off what's going to be changed. It will give you a place to take all these other things into, to help create the change."
SUGGESTED READINGS
Brumbaugh A: Transformation and Recovery: A Guide for the Design and
Development of Acupuncture-Based Chemical Dependency Treatment
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for severe recidivist alcoholism. Lancet 1:1436-1439, 1989,
Guidepoints: Acupuncture in Recovery. The Professional's Newsletter
on Innovative Treatment of Addictive and Mental Disorders.
Shwartz M, Saitz R, Mulvey K, Brannigan P: The value of acupuncture
detoxification programs in a substance abuse treatment system. J
Subst Abuse Treat 17:305-312, 1999.
Smith MO: Acupuncture for Addiction Treatment.
Voyles C: Some Lessons Learned.