Auricular Acupuncture in the Treatment of Cocaine/Crack Abuse

A Review of the Efficacy, the Use of the National Acupuncture Detoxification Association Protocol, and the Selection of Sham Points

by Dr (TCM) Attilio D’Alberto — Journal of Alternative and Complementary Medicine, Volume 10, Number 6, 2004, pp. 985–1000. doi:10.1089/acm.2004.10.985 — cited by 102+ research studies

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1. Abstract
2. Introduction
3. Auricular acupuncture and the NADA protocol
4. Mechanisms of acupuncture
5. Materials and methods
6. Results
7. Discussion: sham points and the Kidney point
8. Addiction according to TCM
9. Conclusions and implications

Abstract

Background: The United Kingdom has had a significant increase in addiction to and use of cocaine among 16–29-year-olds, from 6% in 1998 to 10% in 2000. In 2000, the UK had the highest recorded consumption of “recent use” cocaine in Europe, with 3.3% of young adults. Acupuncture is quick, inexpensive and relatively safe, and may establish itself as an important addiction service in the future.

Aim: To select investigations that meet the inclusion criteria and critically appraise them in order to answer the question: “Is acupuncture effective in the treatment of cocaine addiction?” The focus is then directed toward the use of the National Acupuncture Detoxification Association (NADA) protocol as the intervention and the selection of sham points for the control group.

Data sources: The ARRC database via Trina Ward at Thames Valley University. AMED, MEDLINE® and Embase were also accessed along with hand-searching methods at the British Library.

Inclusion and exclusion criteria: People addicted to either cocaine or crack cocaine as their main addiction, needle-acupuncture, single/double-blinded process, randomised subjects, and a reference group incorporating a form of sham points. Exclusion criteria: moxibustion, laser acupuncture, transcutaneous electrical nerve stimulation (TENS) electroacupuncture, or conditions that did not meet the inclusion criteria.

Quality assessment: Criteria set by ter Riet, Kleijnen and Knipschild (1990); Hammerschlag and Morris (1990); Koes, Bouter and van der Heijden (1995) were modified into one set of 27 criteria.

Results: Six randomised controlled trials (RCTs) met the inclusion criteria. All studies scored over 60 points indicating relatively adequate methodological quality. The mean was 75 (SD 6.80). A linear regression analysis did not yield a statistically significant association (n=6, p=0.11).

Conclusions: This review could not confirm that acupuncture was an effective treatment for cocaine abuse. The NADA protocol of five treatment points still offers the acupuncturist the best-possible combination of acupuncture points based upon TCM. Throughout all the clinical trials reviewed, no side-effects of acupuncture were noted. This paper calls for the full set of 5 treatment points laid out by the NADA to be included as the treatment intervention. Points on the helix, other than the liver yang points, should be selected as sham points for the control group.

Introduction

Prevalence of cocaine addiction in the United Kingdom

Addiction is defined as: “use of a substance that is addictive when it has a mixture of pleasant and unpleasant properties, nearly all of which make the organism function worse, but which also, with continued use, suppress the organism’s awareness of most of the pleasant toxic properties” (Smith, 1979).

In the United Kingdom there has been a significant increase in the use of and addiction to cocaine among 16–29-year-olds — from 6% in 1998 to 10% in 2000. A statistically significant correlation was found between arrestees who tested positive for drug use and all four measures of criminal behaviour. Half of the arrestees held for burglary of non-dwelling premises tested positive for cocaine/crack (DrugScope, 2001).

Past research showed that firm boundaries distinguished recreational users of cocaine powder from problem ‘base/crack’ users and cocaine injectors. However, the boundary between powder cocaine and base/crack may be weakened by an emerging trend in cocaine smoking in recreational and nightlife settings. The UK has one of the lowest prices of cocaine in Europe (around $60.63) and a generally high purity rate. Acupuncture is quick, inexpensive and relatively safe, and may establish itself as an important addiction service for the treatment of cocaine addiction in the future.

Auricular acupuncture and the NADA protocol

Auricular acupuncture points have been characterised as discrete anatomic loci measuring approximately 1–5 mm in diameter in the auricles (Falk et al., 2000). The first record of the auricles’ importance was in the Huang Di Nei Jing, Chapter 28 of the Spiritual Axis (c.100 BCE): “All the vessels congregate in the ear.”

During the 1950s Nogier first developed the practice of auricular acupuncture using the concept that each part of the body is represented on the ear. Wen and Cheung (1973a, 1973b, 1973c) further developed the use of auricular acupuncture in alleviating addiction to opiate-based drugs. In 1985, Michael Smith MD at Lincoln Hospital in the Bronx, New York, developed this research into the newly formed National Acupuncture Detoxification Association (NADA) protocol.

The number of points on the auricle remains unclear; estimates range from 43 to 900 depending on the author (Chen, 1991). Acupuncture acts to relieve withdrawal symptoms and prevent the craving for drugs (Smith and Khan, 1988). The standard NADA points are Shenmen, Sympathetic, Kidney, Liver and Lung.

Mechanisms of acupuncture

Cocaine is believed to exert its euphoric effects by blocking the reuptake of neurotransmitters (primarily dopamine) at nerve synapses in the brain. As a dopamine reuptake inhibitor, cocaine can be considered an indirect dopamine agonist because it potentiates the synaptic actions of dopamine that have been released endogenously.

Blum and colleagues (1996) suggested that stimulating the vagus nerve, located in the concha and at the Lung point on the auricle, with an acupuncture needle stimulates the hypothalamus. Under normal conditions, hypothalamic stimulation initiates the reward cascade: hypothalamic neurons release serotonin (5HT), which activates methionine enkephalin, an opioid peptide. Met-enkephalin is released at the ventral tegmental region and interacts to inhibit receptors controlling the release of γ-aminobutyric acid (GABA). The primary role of GABA is to control the output of dopamine in the ventral tegmental region. The result of inhibiting GABA is an increase in dopamine. Acupuncture acts to reduce craving, thereby assisting the drug addict into self-recovery.

The NADA points act to tonify the Yin of the Liver, Lung, Kidney, Heart (Shenmen) and the Sympathetic region, although this hypothesis of treatment effect has not been investigated within a Western biomedical framework.

Justification for a review of literature

The impact of national drug policies on problem drug use remains unclear because prevalence rates in countries with liberal drug policies (such as the Netherlands) and those with a more restrictive approach (such as Sweden) are not very different. What is clear is that new clients seeking treatment for heroin addiction are decreasing while those seeking treatment for cocaine addiction are increasing (EMCDDA, 2001).

No medication has received widespread acceptance as an effective treatment for cocaine dependency (Rawson et al., 1990). Drug treatment can be divided into the stages of detoxification, rehabilitation and relapse prevention. Acupuncture has been used for all stages of drug treatment.

Materials and methods

Data sources

A literature search was performed using ARRCBASE, MEDLINE® (1966–present), AMED (1985–present) and Embase (1989–present). Hand-searching methods were used at the British Library to capture items that may have been indexed incorrectly or not indexed at all. Examination of reference lists in primary and review articles was conducted. Only full-length, English-language articles were sought. Abstracts and unpublished studies were not selected.

Inclusion and exclusion criteria

Studies were included if they met the criteria: people addicted to either cocaine or crack cocaine as their main addiction; needle-acupuncture; single/double-blinded process; randomised subjects; a reference group incorporating a form of sham points. The inclusion group also consisted of pilot studies. Studies rejected: moxibustion, laser acupuncture, TENS electroacupuncture, or those that did not meet the inclusion criteria. Key words: “cocaine” and “acupuncture”.

Quality assessment

All RCTs were evaluated for methodological quality. The ter Riet et al. (1990) strategy was considered first but was criticised for only having 18 criteria. The criteria were therefore modified to include criteria from Hammerschlag and Morris (1990) and Koes et al. (1995), producing 27 different criteria with weightings. The potential maximum score for each study was 100 points. The higher the score, the better the methodology. One assessor conducted the grading; the assessor was not blinded to the outcomes, so some degree of reviewer bias cannot be excluded.

Results

Six RCTs met the inclusion criteria and were included in this review (Avants et al., 2000; Bullock et al., 1999; Killeen et al., 2002; Lipton et al., 1994; Margolin et al., 2002a; Otto et al., 1998).

Of the six RCTs reviewed, two reported a positive outcome (Avants et al., 2000; Lipton et al. 1994) while four were negative in their conclusions (Bullock et al., 1999; Killeen et al., 2002; Margolin et al., 2002a; Otto et al., 1998). All studies scored over 60 points indicating a relatively adequate quality of methodology. The highest score was 83 (Bullock et al., 1999); the lowest was 64 (Killeen et al., 2002). The mean was 75 (SD 6.80). A linear regression analysis did not yield a statistically significant association (n=6, p=0.11).

Of the six studies, three excluded the Kidney point from the NADA protocol. Three used proximal points; three used helix points, two of which avoided Liver yang points on the helix while one did not.

Discussion: sham points and the Kidney point

There have been many statements made against the use of RCTs in the study of acupuncture. However, until a protocol is found that suits both paradigms of allopathic and traditional medicine, current methodological criteria for RCTs remain the gold standard.

A paradox exists: all six studies scored better than average yet had conflicting outcomes. Lipton et al. (1994) had a positive outcome and a methodology score of 77, while Margolin et al. (2002a) was negative yet scored 79. Therefore this review cannot provide a definite answer as to the efficacy of auricular acupuncture in the treatment of cocaine/crack abuse. The question this raises: in spite of apparently good overall methodology, are certain methodological criteria within the clinical studies causing contradictory outcomes?

The critical importance of sham point selection

The selection of treatment points versus sham points is the most important aspect of any acupuncture research. If ‘sham points’ have active effects, the comparison of outcomes between ‘treatment’ and ‘sham’ groups cannot show the true effect of acupuncture treatment, and the conclusion that treatment had no significant effect can be seriously wrong because the sham points were inappropriate.

Lipton et al. (1994), the first group to replicate the studies of Wen et al. (1973), concluded that acupuncture gave a positive outcome. Further studies found flaws in Lipton et al.’s selection of sham points proximal to active points, undermining the outcome result. Otto et al. (1998) and Bullock et al. (1999) both replicated the Lipton et al. study and concluded with negative outcomes — but in both replicated studies, inappropriate sham points (proximal to active points) were used in the control group.

Avants et al. (2000) used the newly developed selection of sham points on the auricular helix (with a reduced number of treatment points: four instead of the standard five). They concluded with a positive outcome. Killeen et al. (2002) used the full NADA points and non-proximal auricular points, but it is unclear which points were selected on the helix — Liver yang points may have been stimulated in the control group, thus flawing the control. Margolin et al. (2002a) replicated Avants et al. by correctly using the helix without stimulation of the Liver yang points and excluded the Kidney point. The outcome was negative.

The need for standard auricular nomenclature

In any study, both active and sham points must be correctly located, especially upon a body-mass as small as the auricle. This requires detailed and accurate charts of points and anatomic locations. All the studies reviewed relied upon ear maps, but at present no standardised auricular nomenclature exists. There are great differences between the French and Chinese systems — only 39 auricular points have been agreed upon. Some points have more than one name, and new points are constantly being added with new clinical discoveries.

The WHO Working Group decided to withdraw its earlier Auricular Acupuncture Chart because it contained many points and should not be used for further reference. There is a great need for standard terminology in the study of auricular acupuncture: correct anatomic illustrations of the ear; appropriate anatomical mapping of topographical areas; illustrations of correct zones; actual delineation and localisation of points.

Addiction according to Traditional Chinese Medicine

To understand acupoint selection as a treatment modality, it is necessary to understand addiction according to TCM. The NADA protocol is based upon the understanding and relationship of the body’s internal organs, known as the Zangfu. In TCM theory, drug abuse affects mainly the solid (zang, Yin) organs: Lung, Liver, Heart, Spleen and Kidney.

Cocaine abuse generally leads sequentially to four particular syndromes in TCM, which outline the pathology of drug abuse among the Zangfu:

1. Heart Yin deficiency — non-purposive symptoms: excessive sweating, insomnia and anxiety.
2. Kidney Yin deficiency — purposive symptoms: paranoia.
3. Liver Yin deficiency — purposive symptoms: irritability, euphoria and anger.
4. Spleen Qi deficiency — non-purposive symptoms: diarrhoea and loss of appetite.

With the effects of withdrawal and excessive sweating, cocaine destroys Heart Yin and causes Yang to be greater than Yin because a weakened Yin cannot balance or regulate Yang. TCM terms this situation ‘Empty Fire’ or ‘False Fire’. Because Kidney and Heart have a unique relationship according to the Ko (Controlling) sequence of Five Element Theory, Empty Fire drains Kidney Yin. Kidney (Water — Mother of Fire) regulates and controls the Heart (Fire — Child of Water). As the abuse of cocaine depletes Heart Yin (which allows Heart Fire to arise), Kidney Yin is further depleted by excessive demand — the syndrome of Kidney Yin deficiency. This is known as Heart insulting Kidney.

Via the Sheng (Generating) sequence, Kidney Yin deficiency then inhibits the Kidney (Mother of Wood) in its function of supplying Yin to the Liver (Wood, Child of Water), creating the syndrome Liver Yang Rising. The pathologic mechanisms are the same as the Kidney-Heart relationship, although here housed within one organ. Liver Yang Rising further exacerbates the heat syndrome and Yin depletion. The more deficient the Yin, the greater the Liver Yang Rising — perpetuating the cycle.

Liver imbalance leads to Liver-Spleen disharmony. Liver invades Spleen, causing Spleen deficiency. Excessive loss of bodily fluids worsens the Yin deficiency. Injury to Spleen inhibits its function of generating Qi and Blood for the whole body, draining the body’s reserves of pre-Heaven Qi (essence housed within the Kidney) and increasing Kidney Yin deficiency.

Many addicts are involved in excess sexual activity that damages Kidney Yin. Chronic drug abuse may damage Kidney Yang as well as Kidney Yin. The abuse of sex resulting from the False Yang (Empty Heat) increases the Yin and jing deficiency, further exacerbating the False Yang. In some patient populations, the addiction to sex is a primary motivation for the abuse of the drug — these people may be addicted to the False Yang itself.

Allopathic medicine also recognises the relationship between cocaine abuse and kidney damage. A wide spectrum of renal complications can occur with cocaine use, including renal infarction, atherosclerosis of the kidney, renal scleroderma, Henoch-Schönlein purpura and renal failure as a result of rhabdomyolysis (Crowe et al., 2000).

Why the Kidney point must not be excluded

In the six studies reviewed, the NADA protocol was modified to exclude the Kidney point in certain instances. Lipton et al. (1994) and Avants et al. (2000) do not provide any reasoning for the exclusion. Margolin et al. (2002a) justified it as avoiding hyperstimulation of the auricle in the control condition — but there is no clinical evidence that the Kidney point hyperstimulates the auricle.

Margolin et al. (2002a) used dubious reference literature to justify their four-point selection. Of the five articles cited, two gave no logical reasoning for the exclusion, one included the Kidney point, and two excluded both Liver and Kidney. There is no logical reasoning to exclude the Kidney point in any clinical trial. The NADA training manual does not stipulate exclusion of the Kidney point. Sometimes fewer points may be used on clients if they are very sensitive, delicate or young (14–15 years old), but it is a case of using less points rather than excluding one in particular.

Any competent TCM practitioner qualified in acupuncture knows that the Kidney point must be used as the main point of treatment to reduce drug cravings. The landmark auricular study by Wen et al. (1973b) used only the Lung point with good results, and Blum et al. (1996) located it as the place of greatest vagal innervation — but the NADA selection of points, including the Kidney, reduces the signs and symptoms of drug abuse and withdrawal more reliably.

By tonifying the jing-essence and strengthening the Kidney, rehabilitated patients can return to function on the everyday expected level of jing function. Patients need ear-Kidney treatments before they are able to respond to other acupuncture. The critical importance of using ear-Kidney treatment as the primary form of acupuncture for chemical dependency cannot be overemphasised (Smith, 1985).

Conclusions and implications

Implications for professional practice

Even though this review could not confirm the efficacy of acupuncture to treat cocaine abuse, the NADA five-point protocol offers the acupuncturist the best possible combination of acupoints based on TCM theories. Throughout all the clinical trials reviewed, it was impressive to note the low rate of side-effects with acupuncture treatment. Acupuncture is highly cost-effective: overhead costs are low, equipment needs are negligible, and therapy is easily given on an outpatient basis. One acupuncturist supported by a small ancillary staff can treat many patients simultaneously. Increased use of acupuncture therapy may eventually decrease the number of inpatient admissions to expensive treatment centres.

Implications for research

The inconsistency in treatment protocols between studies makes it impossible to draw a strong causal relationship between auricular therapy and its treatment effect. As the form of auricular acupuncture control has moved away from sites located 2–3 mm from active sites to those located on the helix, there is a call for the reintroduction of the Kidney into the acupuncture treatment protocol.

This paper calls for the standardisation of methodology to be implemented systematically across all clinical studies on auricular acupuncture for crack/cocaine abuse:

• The full five treatment points proposed by the NADA should be used as the treatment intervention.
• Points on the helix, other than the Liver yang points, should be selected as sham points for the control group.
• Additional studies are needed to evaluate if endogenous opiate release or hormonal changes occur with sham points on the auricular helix, to assess if the sham treatment is truly placebo.

For a fuller exposition of the TCM mechanisms behind cocaine addiction, see the companion paper Understanding Cocaine Addiction According to Chinese Medicine Theory.

Acknowledgments

I thank Eunkyung Kim B.A., B.Sc. (Hons) T.C.M., Phil Rogers M.R.C.V.S., and Catherine Kerr Med, B.Sc. (Healthcare), Cert.Ed, for their comments and suggestions.

Key references

• Avants, S., Margolin, A., Holford, T.R., Kosten, T.R. (2000). A randomized controlled trial of auricular acupuncture for cocaine dependence. Arch Intern Med, 160, 2305–2312.
• Blum, K., Cull, J., Braverman, E., Comings, D. (1996). Reward deficiency syndrome. Am Sci, 84, 132–145.
• Bullock, M.L., Kiresuk, T.J., Pheley, A.M., Culliton, P.D., Lenz, S.K. (1999). Auricular acupuncture in the treatment of cocaine abuse: a study of efficacy and dosing. J Subst Abuse Treat, 16, 31–38.
• Crowe, A., Howse, M., Bell, G., Henry, J. (2000). Substance abuse and the kidney. QJM.
• Killeen, T.K., et al. (2002). The effect of auricular acupuncture on psychophysiological measures of cocaine craving. Issues Ment Health Nurs, 23, 445–459.
• Lipton, D.S., Brewington, V., Smith, M. (1994). Acupuncture for crack-cocaine detoxification: experimental evaluation of efficacy. J Subst Abuse Treat, 2, 8–17.
• Margolin, A., Kleber, H.D., Avants, S.K., et al. (2002a). Acupuncture for the treatment of cocaine addiction: a randomized controlled trial. JAMA, 287, 55–63.
• Otto, K.C., Quinn, C., Sung, Y.F. (1998). Auricular acupuncture as an adjunctive treatment for cocaine addiction: a pilot study. Am J Addict, 7, 164–170.
• Smith, M.O. (1979). Acupuncture and natural healing in drug detoxification. Am J Acupunct, 2, 97–107.
• Smith, M.O. (1985). Chinese theory of acupuncture detoxification. Am J Acupunct, 13, 385–386.
• Wen, H., Cheung, S. (1973a, 1973b, 1973c). Three foundational papers on treatment of drug addiction by acupuncture and electrical stimulation.

The full reference list (47 sources) is available in the original PDF.