Acupuncture is an accepted treatment worldwide for various clinical conditions, and the effects of acupuncture on opiate addiction have been investigated in many clinical trials. The present review systematically analyzed data from randomized clinical trials published in Chinese and English since 1970. We found that the majority agreed on the efficacy of acupuncture as a strategy for the treatment of opiate addiction. However, some of the methods in several included trials have been criticized for their poor quality. This review summarizes the quality of the study design, the types of acupuncture applied, the commonly selected acupoints or sites of the body, the effectiveness of the treatment, and the possible mechanism underlying the effectiveness of acupuncture in these trials.
Acupuncture, the practice of inserting thin solid needles into specific documented points of the body to treat many different disorders, has been practiced in China since 2500 BC [
Acupuncture needles are either manipulated manually or via an electrical stimulator, that is, “electroacupuncture” (EA). New methods for stimulating the acupoints include applying electric current to skin electrodes over the points, directing a laser light onto the points, or using finger pressure to massage selected points (acupressure). In addition, many new points and entire “microsystems” of points have been described for specific body parts, for example, scalp acupuncture and ear acupuncture (auricular acupuncture). Acupuncture may be useful as an adjunct treatment in comprehensive management programs and might be efficacious in the treatment of pain [
Acupuncture or EA stimulation typically elicits a composite of sensations termed “DeQi,” manifesting as soreness, numbness, heaviness, and distention, which are believed to reflect the efficacy of the treatment [
In 1996, the World Health Organization (WHO) listed 64 medical problems that were considered suitable for acupuncture treatment, including the treatment of drug abuse. There are 3 major advantages regarding the use of acupuncture to treat drug addiction. First, acupuncture therapy for opiate addiction is inexpensive, simple and has no side effects [
The application of acupuncture to opiate addiction originated from a serendipitous observation by Dr. Wen in Hong Kong in 1972. Dr. Wen reported that acupuncture combined with electrical stimulation at 4 body points and 2 ear points relieved the symptoms of opioid withdrawal in persons with opiate addiction [
This method was later adopted in many clinical settings in Western countries, using a protocol developed in 1985 by the head of the US National Acupuncture Detoxification Association (NADA), Dr. M. Smith. The NADA protocol describes the insertion of 5 needles without the use of electrical stimulation bilaterally into the outer ear or auricle at points termed sympathetic, shenmen, kidney, lung, and liver. The NADA protocol advises that 5-point auricular acupuncture relieves withdrawal symptoms, prevents symptoms of craving, and increases patient participation rates in long-term treatment programs [
Auricular acupuncture is the most common form of acupuncture treatment for substance addiction in both the USA and the UK [
A recent advance in this field was made by Dr. Han of Beijing’s Peking University, whose 2005 protocol describes the placement of self-sticking electrodes to the skin over the acupoint followed by electrical stimulation to ameliorate opiate withdrawal signs and prevent relapse of heroin use. The device used for this purpose was named Han’s acupoint nerve stimulator (HANS) [
The mesolimbic dopamine system originates in the ventral tegmental area (VTA) and projects to regions that include the nucleus accumbens and prefrontal cortex, which are believed to play a pivotal role in the development of opiate addiction [
Many studies in animals and humans have demonstrated that acupuncture causes multiple biological responses [
Early works have demonstrated the involvement of
Additionally, acupuncture affects the reinforcing effects of morphine. The method of conditioned place preference (CPP) is a commonly used animal model of drug craving [
In 2008, Yang et al. reviewed the possible mechanism underlying the effectiveness of acupuncture in the treatment of drug addiction and this review provided clear evidence for the biological effects underlying the use of acupuncture to treat drug abuse [
Recent basic studies further support the above-mentioned theory and additionally suggest a role for brain-derived neurotrophic factor (BDNF) in this process. MA at Shenmen (HT7) points regulates the reinforcing effects of morphine via regulation of GABA receptors [
In summary, neurochemical and behavioral evidence have shown that acupuncture helps reduce the effects of positive and negative reinforcement involved in opiate addiction by modulating mesolimbic dopamine neurons. Moreover, several brain neurotransmitter systems involving opioids and GABA have been implicated in the modulation of dopamine release by acupuncture. However, many unanswered questions remain regarding the basic mechanisms of action of acupuncture. Future research could better determine the influence of acupuncture therapy on the regulation of dopamine and other neurotransmitters.
This paper provides an overview of trials that have investigated the clinical effectiveness of acupuncture in the treatment of opiate addiction. We here summarize the quality of the study design, types of acupuncture applied, commonly selected acupoints or sites of the body, and the effectiveness of the treatment in these trials.
In April 2011, a literature search was performed using the following English language databases: PubMed and EBSCOhost. The first search keyword used was “acupuncture” and the second keyword used was either “heroin” or “opiate”.
We included studies that met the following criteria: (1) randomized control trials (RCTs) that adopted a double-blind, single-blind, or nonblind design and (2) participants met criteria for opiate/heroin dependence.
Exclusion criteria included (1) nonnumeric data, (2) comments and replies, and (3) animal study.
Clinical trials on the treatment of opiate/heroin dependence were selected based on the predetermined inclusion and exclusion criteria. Data were extracted from study reports by one reviewer and were verified by a second reviewer. The following key information was extracted from each study: first author, publication year, study design, sample size, characteristics of participants, main acupoints/sites selected, outcome measures, results reported, and adverse events.
We assessed the quality of the studies using the Jadad scale [
An initial search identified 184 published articles from PubMed and 55 published articles from EBSCOhost. Only 10 published articles met our inclusion criteria and these were systematically reviewed (Table
Summary of studies included in the review.
Author (year) | Jadad score | No. of subjects (acup/control) | Mean age (male%) | Inclusion criteria | Intervention type | Treatment frequency (duration) | Treated acupoints | Type of | Outcome measure | Results | Adverse events |
---|---|---|---|---|---|---|---|---|---|---|---|
Washburn et al. (1993), [ | 1 | 100 (55/45) | (1) Standard treatment group: 40.5 (63%) | Self-reported with history of intravenous use of heroin confirmed by physical examination for signs of recent needle use | AA | Daily | Sympathetic | Nonspecific points | (1) Attendance rate | (1) | (1) Slight bleeding |
Wells et al. (1995), [ | 3 | 60/(31/29) | (1) Specific group: — (54.8%) | Only subjects for whom opiates were determined to be the primary drug and who met federal requirements for entry into methadone treatment | AA | Phase I: 5 days per week | Sympathetic | Nonspecific points | (1) Attendance and retention rate | (1) NS | NR |
Zhang et al. (2000), [ | 1 | 181 (121/60) | (1) Specific group: 27.1 (—) | (1) DSM III for opiate dependence | HANS (The frequency was 2/100 HZ; the intensities were 12–16 mA on arms and 16–26 mA on legs) | Phase I: 4 times per day | Hegu (LI4) | Electrodes were placed at the acupoints without any electrical stimulation | (1) Heart rate | All 8 indices improved significantly ( | NR |
Montazeri et al. (2002), [ | 2 | 40 (20/20) | (1) Specific group: 32 (100%) | Self-reported with history of heroin or opium addiction less than 6 months | Body acupuncture with manual stimulation | Once per day for 3 days | Hegu (LI4) | ROD by naloxone | CINA | The acupuncture group had smaller increase in CINA score compared to control group ( | No adverse events |
Wu et al. (2003), [ | 1 | 120 (30/30/30/30) | (1) Acupuncture group: — (—%) | (1) CCMD II-R and DSM III-R for: opiate dependence | Body acupuncture with manual stimulation | Phase I: Twice a day (3 days) | Sishencong (EX-HN1) | (1) Opium plus buprenorphine therapies | (1) Opiate withdrawal scale | (1) Acupuncture group showed significant improvement in withdrawal syndrome after the 6th day ( | Mild dry mouth |
Wen et al. (2005), [ | 2 | 220 (111/109) | (1) Acupuncture group: | (1) DSM IV for opiate dependence | Body acupuncture with manual stimulation | Once a day (10 days) | Hegu (LI4) | Oral administration of lofexidine hydrochloride | (1) Withdrawal symptom | (1) Acupuncture group showed significant improvements in withdrawal syndrome before and after treatment ( | NR |
Margolin et al. (2005), [ | 1 | 40 (20/20) | (1) Five-needle NADA protocol group: 43.1 (65%) | HIV-positive methadone-maintained patients | AA | 5 days per week | Sympathetic | Month 1: | (1) Retention rate | (1) NS | NR |
Zeng et al. (2005), [ | 1 | 70 (35/35) | (1) Treatment group: | (1) DSM III-R for opiate dependence | Body acupuncture with manual stimulation | Once a day (10 days) | Baihui (GV20) | Methadone 10-day decrescendo therapy | Scores of daily withdrawal symptoms | Acupuncture group showed significant improvement in withdrawal symptoms on the 1st, 2nd, 4th, 6th, 7th, 8th, 9th, and 10th days ( | NR |
Mu et al. (2005), [ | 2 | 120 (30/30/30/30) | (1) Acupuncture group I: | (1) ICD-10 for opiate dependence | Body acupuncture with electrical stimulation (The frequency was 5 Hz; the intensity was 5 mA) | 3 times a week (10 weeks) | (1) Acupuncture group I: Jiaji (EX-B2) | (1) Simulation group: ST36, SP6 without electrical stimulation | (1) Withdrawal symptom | In the treatment of 4, 8, 10 weeks, acupuncture groups I and II showed significantly decreased withdrawal syndrome, HAMA, and SDS ( | NR |
Bearn et al. (2009), [ | 3 | 83 (48/34) | (1) Acupuncture group: 36.2 (73%) | DSM IV for opiate dependence | AA | Once a day on weekdays | Five points in the ear cartilage ridge area (acupoints not mentioned) | Application of oil to the ear followed by the attachment of 5 metal clips | (1) Withdrawal symptoms | (1) NS | NR |
Flow diagram showing the number of studies included and excluded from the systematic review.
Five studies mentioned the process of randomization. None of the studies mentioned the use of blinding on clinicians, subjects, or the raters of study outcomes. Four studies [
Five studies [
Ten studies involving 1034 subjects (including those in intervention groups and in control groups) were enrolled, of which 711 cases were from China, 200 were from the USA, 83 were from the UK, and 40 were from Iran. Forty participants were HIV positive.
Four studies [
The reported courses of treatment in 6 studies [
In most of the reviewed studies, the outcome measures included attendance rate, craving scale, and opiate withdrawal symptoms. Seven studies [
Most studies did not mention adverse effects or events, few studies described the monitoring of safety, and only 2 studies [
In the studies included in the review, several used a fixed set of acupoints or sites on their subjects and 1 study allowed some flexibility and needled additional points based on the symptom presentation of individual subjects. The 5 ear acupoints (sympathetic, shenmen, kidney, lung, and liver) were often used in the USA and UK. In China, the acupoints of Zusanli (ST36), Sanyinjiao (SP6), Hegu (LI4), and Neiguan (PC6) were most frequently used for the treatment of opiate addiction. A summary of the main acupoints or sites selected in the studies is presented in Table
Summary of main acupoints/sites selected in the reviewed studies.
Acupoints/sites | Frequency of appearance ( | Percentage ( |
---|---|---|
Zusanli (ST36) | 7 | 31.82 |
Sanyinjiao (SP6) | 6 | 27.27 |
Hegu (LI4) | 6 | 27.27 |
Neiguan (PC6) | 5 | 22.72 |
Shenmen (HT7) | 3 | 13.64 |
Laogone (PC8) | 3 | 13.64 |
Sympathetic (ear) | 3 | 13.64 |
Shenmen (ear) | 3 | 13.64 |
Kidney (ear) | 3 | 13.64 |
Lung (ear) | 3 | 13.64 |
Liver (ear) | 2 | 9.09 |
Waiguan (SJ5) | 2 | 9.09 |
Baihui (GV20/DU20) | 2 | 9.09 |
Dazhui (GV14/DU14) | 2 | 9.09 |
Jiaji (EX-B2) | 1 | 4.55 |
Shenshu (BL23) | 1 | 4.55 |
Sishencong (EX-HN1) | 1 | 4.55 |
Taichong (LR3) | 1 | 4.55 |
Shendao (GV11) | 1 | 4.55 |
Lingtai (GV10) | 1 | 4.55 |
Zhiyang (GV9) | 1 | 4.55 |
Mingmen (GV4) | 1 | 4.55 |
Eight of the 10 trials [
Methodological quality scores.
Washburn et al. [ | Wells et al. [ | Zhang et al. [ | Montazeri et al. [ | Wu | Wen et al. [ | Margolin et al. [ | Zeng et al. [ | Mu | Bearn et al. [ | |
---|---|---|---|---|---|---|---|---|---|---|
(1) Was the study described as randomized? | V | V | V | V | V | V | V | V | V | V |
(2) Was the randomization scheme described and appropriate? | x | V | x | V | x | V | x | x | V | V |
(3) Was the study described as double-blind? | x | x | x | x | x | x | x | x | x | x |
(4) Was the method of double-blinding appropriate? | x | x | x | x | x | x | x | x | x | x |
(5) Was there a description of dropouts and withdrawals? | x | V | x | x | x | x | x | x | x | V |
Results | 1 | 3 | 1 | 2 | 1 | 2 | 1 | 1 | 2 | 3 |
V: yes = 1; x: no = 0; low quality, 0–2; high quality, 3–5.
Although many studies have reported positive findings regarding the use of acupuncture to treat drug dependence, the evidence for its effectiveness has been inconclusive and difficult to interpret [
In this paper, we classified trials as having low quality if they lacked double-blinding, description of withdrawal, and description of randomization. The majority of low-scoring trials displayed positive results regarding acupuncture treatment for opiate addiction. Further, acupuncture treatment showed potential for preventing relapse and reducing the severity of withdrawal symptoms.
Studies receiving a high methodological quality score produced interesting results. Two studies [
Four studies [
Although most of the articles from China reviewed herein have favorable outcome, the type of intervention and needling methods were different between the studies from China and Western countries. Most studies from China used body acupuncture to treat opiate addiction whereas studies from the other countries used auricular acupuncture to treat opiate addiction. In addition, there are various differences in the auricular acupuncture system in different countries. These findings are intriguing considering that these body and auricular points exhibited different efficacies regarding the use of acupuncture to treat opiate addiction.
The most frequently used points or sites for the treatment of opiate addiction by acupuncturists are grouped below based on their locations: points on the extremities: Zusanli (ST36), Sanyinjiao (SP6), Hegu (LI4), and Neiguan (PC6); points and areas on the trunk: Jiaji (EX-B2), Shenshu (BL23), Sishencong (EX-HN1), Baihui (GV20), and Dazhui (GV14); and points on the ear: sympathetic, shenmen, kidney, and lung.
Adverse events associated with acupuncture are infrequently reported and only 2 studies reviewed herein [
Acupuncture is based on the complex TCM theory that an energy (Qi) flows through meridians in each organ and most acupoints are located along one of these meridians. Because diseases are caused by an imbalance or disturbance of Qi, needling at these acupoints can harmonize Qi and cure diseases. Our experience suggests that better therapeutic acupuncture effects are obtained by doctors with several years, or even decades, of clinical training. Without sufficiently trained practitioners, specific therapeutic results may be masked by nonspecific and even placebo effects. Most modern acupuncture trials provide qualification details of the practitioners that performed the therapies. In several trials [
The weakness of this review is the lack of available high-quality data and the results should be interpreted with caution because of the lack of well-designed, high-quality randomized controlled studies. Many studies did not use standard treatment protocols, objective diagnostic criteria, standardized outcome measures, and effective assessment methods. The methodological quality and the description of the studies were poor in the majority of studies.
It is appropriate for a systematic review to calculate the results of each study identified by the study authors only when those studies are sufficiently comparable as to subjects, interventions, and outcomes, and similar enough in design. In addition, the effects of a study intervention on the consequent health or outcomes have to lie in the same direction or show homogeneity. Under these conditions, the individual estimates from each study can be combined to produce a pooled estimate of effect, which is usually more precise than the evidence provided by any of the individual studies. When these conditions cannot be met, it is difficult to interpret the combined findings from individual studies consisting of heterogeneous subjects, interventions, and outcomes.
Although the 10 studies identified by our systematic review shared the same design (randomized control trial), they differed in their inclusion criteria, mode of intervention, and outcome measures. In particular, although 5 outcome measures were used by more than one study (i.e., attendance rate, retention rate, urinalysis, cravings, and withdrawal symptoms), the operational definitions for these measures differed by duration and units of measure. This study heterogeneity prevented us from conducting a statistical analysis.
This review covered a wide body of Chinese and English research investigations into the use of acupuncture for the treatment of opiate dependence from the early 1970s up to 2011. After 35 years of active research by both Asian and Western scientists, this review cannot be used to establish the efficacy of acupuncture in the treatment of opiate addiction because the majority of these studies were classified as having low quality. Although this review may provide a basis for clinicians and future research, future well-designed RCT studies are needed to confirm the efficacy of acupuncture in the treatment of opiate addiction.
J. G. Lin and Y. Y. Chan contributed equally to this work as cofirst authors.
The authors are grateful to Ms. Hui-Yu Hsu for her help in producing the final paper. This work was supported by Grants NSC-100-2320-B-039-029-MY2 and NSC-100-2320-B-039-018 from the National Science Council, Taipei, Taiwan, and in part by Taiwan Department of Health Clinical Trial and Research Center of Excellence (DOH101-TD-B-111-004).