Training Psychiatry Addiction Fellows in Acupuncture

Abstract

Objective

Acupuncture has been studied as an adjunct for addictions treatment. Because many hospitals, outpatient clinics, and facilities are integrating acupuncture treatment, it is important that psychiatrists remain informed about this treatment. This manuscript describes the National Acupuncture Detoxification Association (NADA) protocol and its inclusion as part of the curriculum for psychiatry addictions fellows.

Methods

Psychiatry and psychology fellows completed the NADA training (N = 20) and reported on their satisfaction with the training.

Results

Overall, participants stated that they found the training beneficial and many were integrating acupuncture within their current practice.

Conclusions

Results support the acceptability of acupuncture training among psychiatry fellows in this program.

Acupuncture has been investigated as an adjunct to evidence-based addiction treatments and has been integrated into many treatment centers. A protocol developed by the National Acupuncture Detoxification Association (NADA) seeks to aid patients with substance use detoxification, reduction of cravings, and increased well-being through the insertion of fine-gauge, sterilized needles that are placed in five points in the ear. This practice is called the NADA Five-Point Protocol and is a form of auricular acupuncture [1]. NADA has estimated that over 25,000 practitioners have been trained in this protocol [1]. Acupuncture, a type of Complementary and Alternative Medicine (CAM), has been used to treat addiction with increasing demand. It has been included in the Substance Abuse and Mental Health Services treatment improvement series for treating addiction [2], and the United States Department of Veterans Affairs has integrated acupuncture in many of their hospitals. A recent report indicated that in a survey of 125 Veterans Affairs facilities, 58 offered acupuncture services to patients [3]. Thus, it is incumbent on behavioral health teams, especially those led by psychiatrists, to develop familiarity with this treatment.

The research for the NADA protocol as an adjunct treatment for addictions has largely been supportive of its continued use. One Randomized Controlled Trial (RCT) compared acupuncture (NADA protocol), sham acupuncture (needles inserted into points not identified with addiction), and relaxation control as an adjunct to standard treatment for patients that were addicted to cocaine and receiving methadone maintenance. Results indicated that participants in the acupuncture condition provided more clean urine toxicology screens at the end of the treatment period; however, these results should be interpreted cautiously as there was differential treatment retention between treatment conditions [4]. When this study was later repeated, there were no differences between conditions [5].

The NADA protocol in conjunction with conventional treatment has demonstrated effectiveness in reducing behavioral health symptoms (cravings, depression, anxiety, anger, body aches/headaches, concentration, decreased energy) when compared to the stand-alone conventional treatment [6]. A meta-analysis examined six studies that used acupuncture as a treatment for cocaine use (NADA protocol) and found conflicting results. Ultimately, the meta-analysis was unable to confirm acupuncture as a stand-alone treatment for cocaine use [7]. There is still a need for further research, as acupuncture is a widely available treatment and has demonstrated high patient satisfaction [8].

Within our clinic, acupuncture has been well-received by patients. In our experience patients consistently report a higher quality of sleep, an increased ability to focus, and an overall sense of well-being. Patients have also reported decreases in anxiety, drug craving, and symptoms associated with substance use withdrawal. Also of note, patients have indicated satisfaction with the non-verbal aspect of the intervention; the fact that they are not required to answer questions or verbally interact with a clinician/doctor, allows them to simply “be” in a safe place and experience immediate comfort and relaxation. In addition, patients’ increased satisfaction with this particular intervention perhaps may lead to increases in overall program satisfaction and better overall treatment engagement, a critically important factor in the treatment of addictive disorders.

Because acupuncture is implemented in many addiction treatment centers, it is important that psychiatrists are provided with specific training in the NADA protocol to gain comfort and familiarity with the intervention. We present an overview of the NADA training protocol (conducted by registered NADA trainers) and training satisfaction data from the recipients of the training in our program.

Method

We began implementing the NADA training to addiction psychiatry fellows placed in the Substance Abuse Treatment Unit (SATU) of the Connecticut Mental Health Center (CMHC) in 2009. Our program quickly expanded to include all addiction psychiatry fellows within the Yale University, Department of Psychiatry, Addiction Fellowship. Since then, we have trained clinicians from a variety of disciplines (e.g., psychiatry, psychology, social work, addictions counseling, nursing). At the time of our survey, we had trained 33 addiction psychiatry fellows in five separate cohorts. We incorporated the NADA training into their core curriculum at the outset of the training year, with the belief that participating in the training early in the year might build cohesion within the group as well as give them the opportunity to practice the intervention throughout the year.

NADA-certified trainers provided the NADA training over the course of three days. It is important that trainers experienced in both addiction and mental health provide the training, as the patients requesting psychiatric services often present with both. In addition to NADA registered trainers, Dr. Kenneth Carter is involved in the curriculum; his expertise in the NADA protocol and oriental medicine has been much appreciated by the psychiatry and psychology fellows. The curriculum included the following topics, and the syllabus below was created by Katurah Bryant, RN, LMFT, LADC:

• The NADA Acudetox Protocol: Auricular acupuncture for addictions and behavioral health; Acudetox-based treatment model

• Learning the NADA 5-Point Protocol: Point descriptions and locations; Technique mastery; Trial treatments and clinical experience; Ear seeds/beads/sleep mix tea; Partnership with clients, Communal treatment approach/effects; Boundaries and self-care; Creating the therapeutic atmosphere; Informed consent and client information; Documentation: Reports and record keeping

• The Nature of Addiction and Recovery: Models for understanding addictions and behavioral health and recovery; Treatment models; Pharmacology of psychoactive substances

• Public Health and Regulatory Concerns: Exposure control/safety; NADA clean needle technique

• Research and Acudetox: Trends and outcomes; Future uses in the treatment of addictions and behavioral health disorders

• Integration and Sustainability in Addictions and Behavioral Health: Applications and outcomes; Integration with the treatment milieu; Integration at a systems level; Program sustainability

• Oriental Medicine in the Context of Addictions and Behavioral Health and Treatment: Oriental medicine as related to behavioral health and recovery; “Empty Fire” and crisis management

• Client Management Issues and Strategies: Special populations: Understanding needs and the role of Acudetox in the recovery process

• Ethical and Legal Issues: ADS Code of ethics; Confidentiality/HIPAA; Consent to treatment; Compliance with all federal, state, and local regulations; Supervision

We have found that having a NADA-certified psychiatrist involved in the training has been crucial in promoting its use among psychiatry fellows. In addition to the didactic training, all psychiatry fellows were taught the needle insertion technique during the three-day training. Psychiatry fellows received immediate feedback on their point placement, and they were provided ongoing supervision as they used the technique with their patients. Once they completed 20 supervised treatments, included in the training days, they were certified and able to provide acupuncture services in accordance with local, state, and federal regulations.

Participants were Yale University psychiatry and psychology fellows. An email was sent to recipients of the training requesting their feedback on their training experience. There were 33 psychiatry fellows and 10 psychology fellows that received the NADA training, 20 of which completed the survey. Within the survey, we did not ask respondents to identify if they were from a psychiatry or psychology background because there were too few psychology fellows per cohort (typically one or two), which would have rendered the survey no longer anonymous. However, the sample was predominantly psychiatry addiction fellows. No identifying information was collected and ethical guidelines were followed in accordance with the university’s Institutional Review Board (IRB). The IRB stated that approval was not needed as this survey was anonymous and part of a program evaluation.

A survey was created to assess satisfaction with the training. Participants were asked the year of their training workshop, if they enjoyed the training, if they found it beneficial, if they have ever integrated the training into their practice, and if they were currently integrating acupuncture into their practice. Additionally, participants were asked if the NADA protocol was currently being integrated in their facility and if they had any challenges in integrating acupuncture into their practice. Finally, participants were asked to provide qualitative data on what they valued most about the training. A constant comparative method was used to identify response themes.

Results

There were 20 fellows that participated in the survey. The majority of respondents (70%) had completed the acupuncture training within the previous two years. All participants completed the training within the years 2009 through 2013.

The fellows reported overwhelmingly that they enjoyed the training and that they found it beneficial. No one endorsed the items as finding it non-enjoyable or not beneficial. See Table 1 for item responses. Additionally, 89.47% of the sample indicated that they had some experience in integrating the NADA protocol into their professional practice, and 50% indicated that they were currently integrating the NADA protocol into practice. Sixty percent stated that their current facilities offered the NADA protocol, and 70% stated that they did not have any challenges in integrating the NADA protocol into their practice. A qualitative analysis was performed on the fellows’ responses on what they valued most from the acupuncture training. The following themes were identified: learning a new skillset (n = 8), gaining hands-on experience (n = 6), appreciation for an alternative treatment (n = 3), and developing cohesion between fellows, staff, and patients (n = 3)

Table 1.

NADA Training Satisfaction

	Strongly Agree n (%)	Agree n (%)	Neutral n (%)	Disagree n (%)	Strongly Disagree n (%)
“I enjoyed my NADA training experience”	14 (70)	4 (20)	2 (10)	0	0
“I found the NADA training beneficial”	11 (55)	5 (40)	1 (5)	0	0

Discussion

This program evaluation provided an overview of an acupuncture training curriculum integrated into the core seminar series within a psychiatry addiction residency program. Recipients of the training were emailed a survey regarding their satisfaction with the training and current use of acupuncture. There were 20 individuals that participated in the survey. Overall, their responses strongly supported the inclusion of this innovative adjunctive addictions intervention within the training program. The majority found the training beneficial and reported a history of integrating acupuncture in their professional practice following graduation. In addition, 50% of the respondents were currently implementing acupuncture services.

Participating in the acupuncture training reported the benefit of creating cohesion within the training group, which set a positive, collaborative tone for the rest of the academic training year. We found that the training served as an “icebreaker” in that fellows were performing the treatments on each other at the beginning of the training year. This required a degree of trust, as they were practicing the skill on each other, which helped to build cohesion through humor and vulnerability. This was reflected in some of the responses from the open-ended question of what they enjoyed most from the course (e.g., “The opportunity to practice each day with others in the class”). Another fellow reported that a benefit was “the distinction between client and staff was less pronounced” and that there was an atmosphere of “collegiality of staff.” We also believe that a benefit for including this training within a residency program is the possibility of “seeding” new programs once the residents go on to practice across the country.

There were several limitations to this program evaluation. First, the sample size of 20 was small and not fully representative of all the fellows that received the training (43 fellows were sent the survey.) Additionally, these results are restricted to our training program, and further investigations would need to be conducted to see if our results are generalizable. It will be important for other programs to report on their training methods to best tailor the program to psychiatrists.

These results provide support for the importance of incorporating innovative approaches for the treatment of addictive disorders into core residency education and training. Because psychiatrists lead teams in the treatment of addictive disorders, it is imperative to expose this group to all possible interventions even if they themselves are not administering the treatment, as they will be designing future programs and supervising staff. We believe the incorporation of the acupuncture training into our program provides the opportunity to learn an adjunctive intervention that holds the possibility of increasing treatment engagement with the hope of improving the lives of patients struggling with addiction.

Implications for Educators.

• Acupuncture is an available adjunctive treatment for addiction.

• Psychiatrists are likely to have exposure to acupuncture within their careers, and so it is important they are familiar with the treatment.

• We collected data from 20 psychiatry and psychology fellows that received acupuncture training, and the results demonstrated that they found the training beneficial.