Acupuncture in Addiction Medicine: Its History, Evidence, and Possibilities

Abstract

Substance-use disorders (SUDs) and drug addiction are not only national, but also global health concerns that have worsened during and after the COVID-19 pandemic. Acupuncture augments the endogenous opioid system and, therefore, has a theoretical basis as a treatment for opioid use disorders (OUDs). The basic science of acupuncture, its clinical research in addiction medicine, and decades of success of the National Acupuncture Detoxification Association protocol offer positive findings supporting this protocol's utility for treating SUDs. Considering the mounting opioid/substance-use concerns and deficiencies in SUD treatment availability in the United States, acupuncture can be a safe, feasible treatment option and adjunct in addiction medicine. Furthermore, large governmental agencies are lending support to acupuncture for treating acute and chronic pain, which, in turn, could translate to prevention of SUDs and addictions. This article is a narrative review of the background, the basic science and clinical research, and future direction of acupuncture in addiction medicine.

INTRODUCTION

The United Nations estimated that 309 million people used illicit drugs in 2019. An estimated 62 million people used opioids for nonmedical purposes; the highest prevalence was in North America, with a spike in opioid-overdose deaths since the onset of the pandemic.¹ Worldwide land use for opium cultivation increased by more than a quarter in 2020, with predictions that it will likely increase due to the economic declines from the pandemic, causing financially tenuous countries to turn to illicit drug farming.¹ It was also estimated that 20 million people used cocaine in 2019. Furthermore, more than 40 million Americans had substance-use disorders (SUDs), according to a 2020 National Survey on Drug Use and Health by the Substance Abuse and Mental Health Services Administration.² Drug addiction remains not only a national, but also a global health crisis with resultant profound health and socioeconomic effects.

Treatment plans in addiction medicine, which conventionally center around pharmacologic and psychosocial interventions, remain insufficient or unavailable, especially for adolescents and young adults.³ Medication for addiction treatment (MAT) is standard-of-care for adults with opioid-use disorders (OUDs). Despite the American Academy of Pediatrics recommending MAT for youths with OUD, less than 25% of adolescents and young adults with OUDs are prescribed MAT, and less than 2% of patients younger than 18 years old receive MAT.³ Adult substance-use programs neglect to address the critical psychosocial dynamics of the youth-hood and the child–guardian relationship. Yet, there are limited youth-specific SUD programs.³

Some patients, parents, and clinicians remain reluctant to utilize drug-assisted treatment programs in youths with a propensity toward drug abuse. With the current opioid epidemic disproportionately affecting youth and young adults, acupuncture can be a safe treatment option, with minimal side-effects for treating SUDs. Keeping in mind that it should not be limited to the youth and young adults, acupuncture can provide significant benefit to older patients for whom drug–drug interactions or comorbid medical conditions may be major concerns. Considering the current deficiencies in SUD treatment availability, acupuncture is an alternative or adjuvant treatment to augment the endogenous opioid system.⁴

BACKGROUND

Although acupuncture has been used for thousands of years in Traditional Chinese Medicine, it is only in the last 50 years that acupuncture clinical use and research began in the United States. This development has, in the process, built niches in the treatment of pain as well as in addiction medicine. Acupuncture gained popularity in the United States in 1971 after James Reston, a Pulitzer-prize–winning journalist, fell ill with appendicitis. Published in The New York Times, Reston wrote about his experience in Beijing, where he received acupuncture for his appendectomy and acute postoperative pain.⁵ In 1979, the World Health Organization (WHO) held a symposium on acupuncture.⁶ The participants drew up a list of 43 suitable diseases that acupuncture can help with; this list which was later expanded to include 64 conditions in 1996. In 1997, along with several National Institutes of Health, the panel published a Consensus Statement on acupuncture.⁷ The conclusion of the consensus, after reviewing mounting scientific evidence, was that acupuncture may be an effective adjunct for treating many conditions, including drug addiction.

ACUPUNCTURE'S ORIGINS IN ADDICTION MEDICINE AND THE NADA PROTOCOL

Following Wen's serendipitous discovery of acupuncture in relieving withdrawal symptoms in opium addicted surgical patients in Hong Kong in the 1970s,⁸ Smith (cited in Stuyt and Voyles), director of the Lincoln Recovery Center in New York, developed the National Acupuncture Detoxification Association (NADA) protocol.⁹ This protocol is applied more easily as it uses ear points exclusively and does not require electrical stimulation.

Although the NADA protocol was primarily developed for detoxification, it has been adopted in many clinical settings, including residential facilities, and has been found to reduce the risk of relapse and improve compliance to drug-free treatment programs.¹⁰ The NADA protocol can be applied without needles, using seeds or magnetized metal beads, providing a prolonged, needleless means of stimulation.⁹ Early randomized controlled trials (RCTs) evaluating NADA for treating various SUDs—including alcohol-, opioid-, and heroin-addiction—were promising, but were followed by mixed results.⁹ Later researchers recommended further studies on using the NADA protocol to supplement more-conventional treatments versus using conventional treatment alone, recognizing that it may be more successful when incorporated into a whole person psychosocial treatment plan.⁹

INTEGRATION OF BASIC SCIENCE RESEARCH

Han (of Peking University), the pioneer of the endorphin theory in acupuncture, devoted more than 3 decades of research on acupuncture analgesia. He confirmed, in multiple large-scale studies, that acupuncture stimulates opioid-peptide production and release in the central nervous system (CNS), producing significant antinociceptive effects.¹¹

Paving the way for acupuncture research on opioid addiction. Han found that endogenous opioid effects of electroacupuncture (EA) were frequency-dependent. More specifically, low-frequency (LF; 2 Hz) stimulation increased enkephalin and endorphin levels, whereas high-frequency (HF; 100 Hz) increased dynorphin levels.⁴ Han and his team found that HF EA was more effective than LF EA for suppressing withdrawal syndromes in morphine-addicted rat models, which was consistent with literature revealing that dynorphin can suppress withdrawal syndrome in heroin-dependent humans.¹² In lieu of acupuncture needle placement Han, working with Ma et al., used transcutaneous electrical acupoint stimulation (TEAS); TEAS through skin pads was effective for suppressing heroin-withdrawal symptoms and cravings.¹³

Acupuncture has a bidirectional role in addressing drug addiction, facilitating recovery of homeostasis or biochemical balance in the CNS.¹⁴ Lee et al. theorized that acupuncture “normalizes hyper-reactive or hypoactive states of the mesolimbic dopamine system” in drug addiction, analogous to the Yin and Yang theory of acupuncture. Through regulation of neurotransmitters that contribute to addictive behaviors, acupuncture can prevent drug-use relapse by attenuating the positive reinforcement of drug-sensitized reward pathways and providing negative reinforcement of withdrawal. The acupuncture points commonly used in experimental studies on acupuncture for drug addiction include HT-7, LI-4, LI-5, LR-2, LR-3, KI-9, KI-3, KI-10, SI-5, SP-6, ST-36, and ST-44.¹⁴ It was proposed that acupuncture, being a bidirectional therapeutic intervention to alleviate both cravings and withdrawal, is a promising solution to drug addiction.

Animal studies have been used to elucidate the mechanism and efficacy of acupuncture for treating chronic pain and opioid addiction. It is known that chronic morphine administration causes physiologic and histologic changes in the mesolimbic dopamine system.¹⁴ This neural system originates in the ventral tegmental area (VTA) and projects anteriorly to the nucleus accumbens and prefrontal cortex. Chu et al. demonstrated for the first time that peripheral electrical stimulation (PES), a modified form of acupuncture, accelerates recovery of morphologic changes in the VTA of morphine-withdrawal rats.¹⁵ They also found that PES increases expression of BDNF [brain-derived neurotrophic factor], a protein that supports growth and recovery of neurons, in morphine-withdrawal rats.¹⁵

Acupuncture has been shown to have neuroprotective effects against heroin-induced brain injury in rats.¹⁶ EA has been effective for treating morphine-abstinence syndrome in rats, characterized by attenuation of wet shakes, teeth chattering, weight loss, and penile licking.¹⁷ EA has significantly suppressed morphine-induced conditioned place preference, a learned preference for one place over another, due to pairing of the location with a reward event.^14,17 Taken together, there is histologic, neurochemical, and behavioral evidence in rat models that support using acupuncture to treat opioid addiction.

Reduction of drug sensitization with acupuncture has been demonstrated in animals. Kim et al. found acupuncture with manual stimulation, compared to sham acupuncture, significantly reduced morphine-induced dopamine release in the nucleus accumbens and behavioral hyperactivity in rats sensitized to morphine.¹⁸ Similar results were seen in methamphetamine-sensitized mice using EA, compared to sham EA.^19,20 EA was also found to reduce heroin-seeking behaviors in rats.²¹ Acupuncture was found to attenuate cocaine-induced dopamine release via VTA γ-aminobutyric acid (GABA) pathways and inhibit stress-induced reinstatement of cocaine-seeking in rats.²² Yang et al. found acupuncture inhibited dopamine release in the nucleus accumbens through VTA GABA modulation and reduced self-administration of ethanol in rats.²⁰ Considering the association between drug sensitization and relapse, these animal studies demonstrate that acupuncture may be helpful for reducing relapse in addiction.

CLINICAL RESEARCH

The majority of studies reported positive findings in support of using acupuncture to treat opioid addiction; however, conventional scientific evidence for its effectiveness is difficult to interpret due to poor quality, small sample sizes, lack of randomizations or control group, and limited descriptions of methodology in many of reviewed trials.¹⁷

An exploratory study evaluated the benefits of adding auricular acupuncture 3 times per week to a 21-day outpatient, structured, psychoeducational treatment program for women with concurrent substance use problems, anxiety, and depression.²³ Women who received auricular acupuncture in a protocol similar to the NADA protocol reported fewer cravings, less depression, and less anxiety.²³

Chen et al. explored the efficacy of acupuncture for treating OUD in 9 studies with 1063 participants.²⁴ The researchers concluded that acupuncture reduced withdrawal symptoms, including cravings, insomnia, and depression, compared to no treatment/sham acupuncture. EA reduced cravings and depression, compared to sham EA.²⁴ TEAS was found to reduce insomnia and anxiety, compared to no treatment/sham TEAS.²⁴ The researchers noted that there was insufficient evidence to conclude that acupuncture was better than medication for treating OUD.²⁴

In another systematic review and meta-analysis of 41 studies with 5227 participants with SUD, Grant et al. identified significant differences in favor of acupuncture with regard to craving and anxiety, but not in relapse compared to comparators. However, the researchers noted evidence of publication bias.²⁵

Although there are many international studies investigating the use of acupuncture for treating SUD and addiction, most published reviews and meta-analyses report difficulty with collating data due to study heterogeneity and variations in acupuncture practice. In addition, many studies are heavily criticized for poor study designs and quality. Although NADA auriculotherapy may not be scientifically demonstrably effective for reducing acute opiate craving or withdrawal, the protocol may facilitate recovery as an adjunctive treatment by decreasing methadone detoxification and maintenance dosages and by increasing treatment retention.²⁶

Acupuncture can be used to treat neonatal abstinence syndrome (NAS). A case study reported improved feeding and reduced Finnegan scores 1 day after auricular laser was applied using the NADA protocol.²⁷ One pilot study of 10 neonates reported reduced need for rescue doses 48 hours after treatment.²⁸ In a prospective, blinded RCT of 28 newborns, duration of morphine therapy and length of hospital stay were reduced in an acupuncture group, compared to a pharmacology-alone group.²⁷ In a study of 76 neonates with NAS after in utero exposure to maternally ingested opiates, there was no significant difference in length of stay in the auricular acupressure group versus the control group.²⁹ In a review of 19 studies evaluating acupuncture use to treat NAS, Jackson et al. concluded that acupuncture is safe and has demonstrated benefits for reducing symptoms of opioid withdrawal, including feeding difficulties, disrupted sleep, pain, and agitation.³⁰

With the paucity of large high-quality studies in humans, there are functional magnetic resonance imaging (fMRI) findings that support laboratory animal studies, demonstrating acupuncture's effect in bench-work investigations. Acupuncture has been shown to produce extensive deactivation of the limbic–paralimbic–neocortical system as seen on fMRI in humans.³¹ Acupuncture reduced heroin cue–induced activation on fMRI in areas of the brain involving psychologic craving.³² Interestingly, acupuncture was recently found to modulate reward and habit systems on fMRI of adolescents with internet addiction.³³

FUTURE DIRECTIONS

With ancient value in Traditional Chinese Medicine and positive findings in contemporary evidence-based medicine, acupuncture shows promise for treating patients of all ages. Future examinations of the efficacy of acupuncture in addiction medicine should include well-designed studies with thoroughly written methodologies and long-term follow-ups. Specifically, examination of patient symptomatology in addition to objective data measuring withdrawal symptoms, length of hospital/rehabilitation stays, longevity in outpatient program adherence, and reduction of associated health care costs have potential to demonstrate clear benefits. There is an opportunity to explore acupuncture's clinical utility not simply as a lone treatment, but in combination with existing therapeutic interventions in the treatment of substance use disorders.

CONCLUSIONS

Despite growing public acceptance of the practice of acupuncture, access to acupuncture therapy has been limited. Insurance coverage is slow in expanding to include complementary medical therapies. This is important in not only providing acupuncture to treat addiction, but also to treat chronic pain, which, in turn, could translate to preventing substance abuse and addiction. It is encouraging that the U.S. Department of Health and Human Services included acupuncture in the Pain Management Best Practice Task Force Report, validating its usefulness in the treatment of pain.³⁴ Such government support will propel public and industrial awareness further regarding the efficacy of acupuncture. The Task Force also acknowledged the importance of broadening insurance coverage and payment for all chronic- and acute-pain treatments, including complementary therapies. With larger, higher-quality studies and increased recognition of the value of acupuncture through national organizations, incorporation of acupuncture in Western medicine and addiction medicine is promising.

AUTHOR DISCLOSURE STATEMENT

No financial conflicts of interest exist.

FUNDING INFORMATION

No funding was received for this article.

To receive CME credit, you must complete the quiz online at: www.medicalacupuncture.org/cme

CME Quiz Questions

Article learning objectives: After studying this article, participants should be able to describe the use of acupuncture for substance use disorder in America; state the prevalence of substance use disorder and how it has changed over time; and identify the possible benefits of acupuncture in substance use disorder.

Publication date: May 16, 2023

Expiration date: May 31, 2026

Disclosure Information:

None of the authors, editors, or reviewers of this educational activity, have relevant financial relationship(s) with ineligible companies to disclose.

Questions:

• 1.The 2019 estimates for opioid use in non-medical disorders was which of the following

• A. 62 million people

• B. 1 million people

• C. 200 million people

• D. 150 million people

• 2.Which of the following statements best describes estimates of illicit drug use in 2019.

• A. The highest prevalence was seen in Asia

• B. The highest prevalence was seen in North America

• C. The highest prevalence was seen in Central America

• D. The highest prevalence was seen in South America

• 3.Which of the following best describes the NADA protocol

• A. Best done with electrical stimulation

• B. Must be used with needles

• C. Can be used to reduce relapse and increase compliance

• D. Used only in hospital settings

• 4.Which of the following best describes how acupuncture modulates pain

• A. By activating the sympathetic nervous system

• B. By lowering dopamine levels and raising serotonin levels

• C. By decreasing levels of dynorphin

• D. By normalizing hyperactive or hypoactive states of the mesolimbic dopamine system

• 5.The NADA protocol can be useful in which of the following instances.

• A. Neonatal abstinence syndrome

• B. Cardiogenic shock

• C. Temporal arteritis

• D. Ramsay-Hunt syndrome

Continuing Medical Education – Journal Based CME Objectives:

Articles in Medical Acupuncture will focus on acupuncture research through controlled studies (comparative effectiveness or randomized trials); provide systematic reviews and meta-analysis of existing systematic reviews of acupuncture research and provide basic education on how to perform various types and styles of acupuncture. Participants in this journal-based CME activity should be able to demonstrate increased understanding of the material specific to the article featured and be able to apply relevant information to clinical practice.

CME Credit

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