Selasa, 27 Januari 2009

Auricular acupuncture and substance misuse: a clinical audit

By: Blacker, Paul

Abstract

This article reports on a clinical audit of a substance misuse service in Kent (UK). The audit assessed the efficacy of auricular acupuncture treatment of the symptoms commonly associated with addiction, as well as measuring its benefits in the clinical management of substance misuse. The results suggest that regular auricular acupuncture treatment has significant benefits to offer clients of drug and alcohol rehabilitation services, and that it is a safe and cost-effective treatment that is particularly effective in helping to retain clients in treatment.

Keywords: Substance misuse, ear acupuncture, auricular acupuncture, addiction, rehabilitation, drugs, alcohol, NADA.

Introduction

Evidence for the efficacy of acupuncture in the treatment of substance misuse is sparse but encouraging, particularly with regard to its success in retaining clients in treatment (British Acupuncture Council, May 2000). Acupuncture has also been shown to be effective at treating some of the symptoms commonly associated with substance misuse, such as headaches (British Medical Journal, 2004), anxiety (Apostolopoulos et al, 1996) and neck pain (British Medical Journal, 2001).

The use of auricular acupuncture to treat people with substance misuse problems has been growing steadily since the 1970's, when a specific five-point protocol was developed at the Lincoln Clinic in New York. The National Acupuncture Detoxification Association (NADA (1)) was established in 1985 to promote this protocol, which is now considered to be the standard acupuncture treatment for drug and alcohol addiction.

The substance misuse service at the Kent and Medway NHS and Social Care Trust began in January 1998, and provides regular ear and body acupuncture to assist clients in various stages of recovery. Auricular acupuncture has been recommended by the Department of Health as appropriate for the treatment of clients in tiers 1 to 4 (2) of their model multidisciplinary treatment framework (Department of Health, 2002). A significant advantage of acupuncture treatment is that it is complementary to conventional treatments, and easily integrates into a multidisciplinary recovery programme. In terms of research, however, this makes it very difficult to isolate the effects of acupuncture from those of other interventions.

Acupuncture is readily available in 86 percent of NHS pain clinics (British Medical Association, 2000), but is not yet as widely available for the treatment of substance misuse. A report by the British Medical Association recommended that acupuncture should be integrated into the NHS, and that research should be directed towards "investigating ... medical conditions treated by acupuncture to ensure that patients who could gain the most benefit have access to acupuncture on the NHS" (British Medical Association, 2000). With this in mind, the following audit (3) was undertaken to ascertain the benefits of regular auricular acupuncture treatment for the clients of substance misuse services.

Methodology

The audit was conducted by a team of four members of the Substance Misuse Team, all fully trained acupuncturists and registered with the British Acupuncture Council. The audit focused on three main questions:

1. Is auricular acupuncture effective in the treatment and clinical management of substance misuse?

2. What benefits does auricular acupuncture bring to clients with regard to symptoms associated with their drug use?

3. Which areas of the service could be improved in terms of delivery of acupuncture to the clients?

Acupuncture treatment was based on the points used in the NADA protocol: bilateral Sympathetic, Shenmen, Kidney, Liver and Lung (upper or lower). At the initial consultation every client was asked to complete a new-patient form, based on the MYMOP (Measure Yourself Medical Outcome Profile) form. After every five treatments clients were asked to complete a follow-up questionnaire (4). The signs and symptoms studied in the audit were considered to be those most commonly associated with drug and alcohol withdrawal. Treatment rooms were open plan, and whilst treatment duration was not strictly monitored, clients were encouraged to remain seated with the needles in place for a minimum of 40 minutes.

Clients were able to access the service as often as required. During the audit 53 new clients were seen, with 80 follow-up forms completed (over 450 completed treatments). The majority of the service-users attended the acupuncture clinic regularly: 60 percent of clients attended the acupuncture clinic over 15 times. Seventy-two percent of the clients were aged 30 or older, with just six percent aged between 18 and 25. Many of the clients who attended the clinic were multiple substance users, with 17 percent of both male and female clients regularly using five or more different substances.

Results

Thirteen common drug-withdrawal symptoms were monitored. When clients completed a new-patient questionnaire, they were asked to rate the severity of each symptom as either mild, medium, strong or extreme. In the follow-up questionnaire they were asked to re-estimate the intensity of their symptoms. For the sake of clarity, this article focuses only on the strong and extreme symptoms. The following two graphs show how the number of clients rating their symptoms as either strong or extreme changed as a result of acupuncture treatment.

In addition to rating the intensity of each symptom (as above), each follow-up questionnaire asked clients to indicate whether specific symptoms had reduced, stayed the same or increased in intensity. The following discussion indicates clients' experience of changes in these symptoms after acupuncture treatment.

Stress

Forty-eight percent of clients reported reduced levels of stress. Stress is an identified high-risk event for clients; reduction in a client's stress levels leads to a reduced risk of reusing.

Mood swings

Fluctuations in mood are particularly problematic for clients withdrawing from drugs and alcohol, and many will attempt to dull any emotional distress by reusing. 42 percent of clients initially reported strong or extreme fluctuations in their mood (see Figures 2 and 3), which dropped to 22 percent after treatment.

Cravings

Acupuncture treatment did not seem to improve clients' experience of their cravings. Figures 2 and 3 show that strong and extreme cravings actually increased after treatment. This is likely to be a direct result of clients' abstinence: a reduction in drug or alcohol intake inevitably leads to heightened cravings for that particular substance.

Anxiety

44 percent of clients reported strong or extreme anxiety at their initial consultation. Whilst 20 percent of clients reported improvements in their anxiety, 14% reported a worsening of this symptom. Anxiety is a typical symptom associated with drug withdrawal, and this increase is likely to be a natural consequence of reducing drug intake.

Loss of appetite

The eating habits of people addicted to drugs and alcohol are frequently poor. The body requires proper nutrition in order to heal itself, and therefore an improvement in a client's appetite can be a very beneficial result of treatment. Following acupuncture treatment 63 percent of clients reported improvements in their appetite.

Depression

48 percent of clients were experiencing strong or extreme depression prior to acupuncture treatment; in the follow-up questionnaire only 29 percent reported this symptom.

Panic attacks

34 percent of clients initially reported suffering from strong or extreme panic attacks. After treatment this had dropped to 16 percent.

Physical pains

Many of the substances used by clients have pain relieving effects. When clients stop using drugs and alcohol, aches and pains commonly reappear. 32 percent of clients initially reported strong or extreme physical pains, which reduced to 17 percent after treatment.

Feelings of paranoia, obsessive behaviour, obsessive thoughts

There appeared to be little improvement in feelings of paranoia, obsessive behaviour or obsessive thoughts.

Low energy

No clear pattern emerged with regards to changes in clients' energy levels. Clients rating this symptom as strong suffered a worsening of their energy levels, whilst those with extremely low energy noticed an improvement.

Sleep

Many people engaged in substance abuse are chronically deprived of proper sleep. Time spent with the eyes closed tends to be either exhaustion or drug-induced unconsciousness. Better sleep brings improved energy and a more stable mood. Fiftyfour percent of clients reported improved sleep after treatment.

Substance use

Clients were asked to state whether their substance use had altered in any way. The following graph shows how substance use changed following acupuncture treatment.

Figure 4 clearly illustrates the effectiveness of regular auricular acupuncture treatment in helping clients manage their addictions. The main substances reduced or stopped were alcohol (54 percent), cannabis 28 percent), cocaine (25 percent), heroin (25 percent) and crack (24 percent). These results are supported by similar findings in a previous audit of auricular acupuncture services in Kent (Andrews, 1998).

Conclusion

The results of this audit clearly show that regular auricular acupuncture treatment significantly ameliorates many of the symptoms commonly associated with drug withdrawal, as well as helping clients to manage their use of drugs and alcohol. Over half of the clients attending the acupuncture clinic reduced or stopped their alcohol use, whilst a quarter of the clients reduced their heroin, cocaine, crack, cannabis and tobacco use. Clients returned to the clinic for an average of twenty treatments over the six-month period, which, in itself suggests that acupuncture effectively helped them to engage in their own recovery.

For every pound spent on the treatment of substance misuse there are savings of 9.50 [pounds sterling] in the criminal justice system (Home Office, 2006). Based an average of nine treatments per clinical session, average equipment costs (see Blacker et al, 2004), and an average salary (see Turning-Point, 2007), the cost per client per treatment would be between 2.43 [pounds sterling] and 3.08 [pounds sterling]. In a clinic treating 45 clients per week, this could give savings to the government of between 1,038.83 [pounds sterling] and [pounds sterling]1,316.70 per week. Given the evidence above, this makes acupuncture an extremely cost-effective treatment option for substance misuse services.

References

Andrews K. March (1998). "Complementary Clinic auricular therapy first report", Thames Gateway NHS Trust; Kent.

Apostolopoulos A, Karavi M (1996). "Overeating; treatment of obesity and anxiety by auricular acupuncture, an analysis of 800 cases", Acupuncture in Medicine; Warrington.

Blacker P, (2006). "Efficacy of ear acupuncture in the treatment of substance misuse, Kent", West Kent NHS and Social Care Trust; Kent

Blacker P, Kozak O (2004). "Auricular therapy 5 year audit 1998-2003, Kent", West Kent NHS and Social Care Trust; Kent.

British Acupuncture Council (2000). "Briefing Paper No 7, Substance Abuse and acupuncture, the evidence for effectiveness", British Acupuncture Council; London.

British Acupuncture Council (2005). "Substance abuse and acupuncture the evidence for effectiveness", British Acupuncture Council; London.

British Medical Association (2000). "British Medical Association board of science and education, Acupuncture efficacy safety and practice", British Medical Association; London.

Department of Health (2002). "Models of care for treatment of adult drug miss-users, framework for developing local systems of effective drug misuse treatment in England", National Treatment Agency for substance misuse; London.

Ear Acupuncture Register, http://www.yuantmc. co.uk--accessed 17 July 2007

Home office www.drugs.gov. uk/drug-strategy/factsand-statistics/?version=1 --Accessed 17 July 2007

Irnich et al( 2001). "Randomised trial of acupuncture compared with conventional massage and "sham" laser acupuncture for treatment of chronic neck pain", BMJ, June 2001, 322:1574.

MYMOP information: http:// www.bristol.ac.uk/hrsc/ research/other/mymop --Accessed July 2007

NADA: http://www. acudetox.com--Accessed 17 September 2006.

NADA UK: http://www. nadauk.com--Accessed 17 July 2007

Turning Point: http://iris. turning-point.co.uk/ C7/HR%20Manual/ Document%20Library/ Performance%20Mana gement%20Policy.pdf--Accessed 17 July 2007

Vickers A et al (2004). "Acupuncture for chronic headache in primary care: large, pragmatic, randomised trial", BMJ, 27 March 2004, 328:744

Footnotes

(1) NADA UK was formed in 2006.

(2) Tier 1: Non-substance misuse specific services requiring interface with drug and alcohol treatment.

Tier 2: Open access drug and alcohol treatment services.

Tier 3 : Structured community-based drug treatment services.

Tier 4: Residential services for drug and alcohol misusers; Tier 4a: Residential drug and alcohol misuse specific service; Tier 4b: Highly specialised non-substance misuse specific services (Department of Health, 2002).

(3) A copy of the full audit can be obtained from the author--see end of article for contact details.

(4) Copies of these forms can be obtained directly from the author--see end of article for contact details.

Paul Blacker has been practising acupuncture since 1997. He works as the lead acupuncturist for Turning-Point (perviously Substance misuse department Kent & Medway NHS and Social Care Trust). He also teaches acupuncture at the College of Naturopathic Medicine in London, and sits on the Auricular Acupuncture Stakeholders Group, pursuing voluntary self-regulation of the auricular acupuncture profession. He can be contacted at paulblacker@mac.com

Table 1: Distribution of number of substances used by gender

Number of
Substances
Used Male % Female

1 46 17

2 13 13

3 7 31

4 17 22

5 or more 17 17

Figure 1: Percentage of clients using individual substances

Top 8 drugs used

% ge

Alcohol 66
Tobacco 57
Cannabis 36
Heroin 25
Benzodiazepines 23
Antidepressants 17
Methadone 15
Crack

Note: Table made from bar graph.

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