ACUPUNCTURE AND DRUG TREATMENT
Martin Rickler, Ph.D.
The Paladin Group
LITERATURE REVIEW: 1993
Acupuncture has been a traditional oriental medical treatment for over 2,500 years, but has only come to awareness in the western world sporadically in brief bursts over the past two hundred years. Most of that awareness occurred in this century after World War I, World War II, and following Richard Nixon's visit to China in 1972 (Brumbaugh, 1993). Chinese medical theory proposes that acupuncture seems to work in a homeostatic way to restore physiological balance by moving energy to the place that it is needed in the body. This energy, or chi, circulates through the body in streams, or meridians. The needles placed in the acupuncture points on the meridians stimulate the flow of the chi energy to either increase or decrease the functioning of the body part influenced by the acupuncture site. Thus, if a body organ such as the stomach needs to be stimulated, acupuncture at a particular point will cause the energy to flow to increase stomach activity. If the stomach needs to be calmed, acupuncture at the same site will cause the energy to flow to reduce stomach activity (Brumbaugh, 1993).Acute Withdrawal Treatment. There are currently more than 175 acupuncture-based chemical dependency programs operating in the United States and acupuncture is beginning to build a body of literature to demonstrate its effectiveness in treating the acute withdrawal symptoms of alcohol and other drug abuse (Brumbaugh, 1993; Karrell, 1990; Renaud, 1990; Smith & Khan, 1988). While many of the reports are anecdotal (as Benedict, 1990; Pinkney, 1990), clinical observations are consistent and striking to watch. An observer entering an acupuncture clinic may see clients as diverse as businessmen and women, blue collar workers or street people. A typical client presenting for detoxification may appear with sweating and shaking hands, pasty white face, and an intense manner. Within fifteen minutes of having the acupuncture needles inserted in the client's ears, most outside observers will report seeing the client to appear much calmer, reduced shaking of the hands, and to appear to have experienced a lessening of the acute trauma of drug withdrawal symptoms. Self-reports of clients concur with the outside observations, some even reporting euphoria, a "high", or some altered state of consciousness as well as a reduced desire to "fix". The self-report of the Chief of the Santa Barbara Police Department upon experiencing acupuncture to determine its effects on a first hand basis are consistent with other anecdotal evidence: "it's very calming. There definitely is something going on there," (Breza, 1991).
Experimentally, the target populations are almost always long-time recidivist alcoholics who have been most resistant to treatment. The typical type of study, whether experimental or anecdotal, divides a single group of practicing alcoholics into one group that receives auricular (ear) acupuncture, and one group that does not. Sometimes both groups get counseling, sometimes not. Results have been very encouraging for the utilization of acupuncture on this most difficult population (Bullock, Culliton, & Olander, 1989).
Drug Treatment Studies. As with the alcohol treatment studies, drug treatment studies have usually specified active, practicing heroin or cocaine addicts as the target population. These studies have also shown very promising results for the use of acupuncture as a detoxification and initial treatment modality (Renaud, 1990; Smith & Khan, 1988). Clients addicted to heroin will frequently report that the acupuncture treatment gives them a feeling of euphoria, and will also report that it is euphoria that helps reduce the symptoms and cravings of withdrawal (Brumbaugh, 1993).
The Lincoln Hospital Clinic. The Lincoln Hospital Clinic in the South Bronx, New York serves as one of the principle acupuncture drug treatment sites for the western world. Dr. Michael Smith, who has been conducting these treatments at the Lincoln Hospital Clinic in 1974, also founded the National Acupuncture Detoxification Association (NADA) in 1985 which trains and certifies physicians and health professionals in the use of acupuncture as a detoxification methodology. The Lincoln Clinic uses acupuncture to treat 250 substance abusing patients daily with over 1,000 patients referred to the clinic annually from welfare and criminal justice agencies. The clinic utilizes urine testing and traditional counseling techniques along with acupuncture and reports that 60% of all of it's clients since 1972 have stopped their drug abuse (as verified by urine tests) and that more than 50% of their 8,000 crack patients have been able to provide clean urine tests for time periods exceeding two months (Benedict, 1990; Brumbaugh, 1993; Pinkney, 1990; Renaud, 1990; and Smith & Khan, 1988).
Placebo Acupuncture Studies. Recent studies have begun to control for placebo effects of receiving acupuncture by dividing the study population into two groups, one that obtains "real" auricular acupuncture, and one that obtains "sham" acupuncture with the needles placed in close proximity to the active points, but in points known to have no real effect. These studies, mostly blind, are demonstrating strong effects of the real acupuncture over the sham treatments. The hallmark studies for placebo acupuncture are from the Bullock group in Hennepin County Minnesota. In a residential program where only the acupuncturists knew who the real forty and sham forty clients were, twenty-one patients of the "real" acupuncture group completed the entire treatment program, while only one of the "sham" acupuncture group completed treatment. Even six months following the end of treatment, without any continuing treatment, the "real" acupuncture group continued to report less of a need for alcohol, had half the number of drinking episodes, and had half the number of readmissions to detoxification centers (Bullock, et al, 1989). Another study in California (Clark, 1990) also utilized a single blind design and showed that clients who received the "real" acupuncture detoxification attended the clinic for more days and also stayed in treatment longer than clients receiving the "sham" treatment.
Cultural & Ethnic Factors. While the acceptance of acupuncture has met resistance by the general western world, it is more readily accepted and utilized by non-white cultures and ethnic groups. Acupuncture detoxification and treatment programs have been set up in a dozen western countries outside of the United States and are in the process of being implemented in many other locales. Attendance reports from clinics in the United States indicate that acceptance of acupuncture as a treatment modality has been demonstrated in Native American tribes, by urban Blacks in the United States, and by Latin American immigrants (Clark, 1990; Smith, 1989; Smith & Khan, 1988).
TRADITIONAL CRIMINAL JUSTICE DRUG TREATMENT
Jail Treatment Programs. Jails in the United States have traditionally served the purpose of either detaining inmates while they wait for their case to be heard, or to house inmates who are serving relatively short sentences when compared to prison terms. Jails provide a unique opportunity to intervene on inmates who have alcohol or other drug abuse problems. Inmates are confined in a controlled space, may have few recreational or work diversions, and may be motivated to participate to satisfy the courts. They are taken out of society for a brief enough time that they may not become fully institutionalized, as do inmates serving much longer prison terms. This window of opportunity is particularly salient when considered against the report that as many as 43% of inmates newly arrested and processed through metropolitan jails in the United States in 1989 self-indicated a need for treatment for alcohol or other drug abuse problems (NIJ survey reported in Peters, 1993). Despite this great need for alcohol and drug treatment services, only 28% of U.S. jails provide any substance abuse services at all, mostly consisting of in-jail meetings of Alcoholics Anonymous. While 7% of U.S. jails report that they provided a comprehensive level of substance abuse treatment services, not even 1% of the jails provided an option for the inmate to have 10 hours per week of services. Thus, while the link between drug abuse and crime is firmly established, and jails provide an ideal opportunity to intervene on the substance abuse problems, the overwhelming majority of inmates most in need of these services don't have the option to utilize them (Peters, 1993). (The same holds true for state prison populations, where it is estimated that only about 11% of inmates were enrolled in drug treatment programs and that two-thirds of those needing the programs were not being treated (Brown, 1992).)Theoretical Approaches to Jail Treatment. Peters (1993) summarizes the four major treatment approaches utilized in jails in the United States. This most up to date review lacks any mention of the use of acupuncture as a treatment or adjunct to treatment for jail programs.
- The Chemical Dependency/Self-Help approach uses a twelve-step model, often accompanied by counseling and education. An example of this model is the five-week program in the King County Jail which provides educational seminars to inmates, twelve-step orientation and meetings, anger and stress management, aftercare planning and vocational rehabilitation.
- Pharmacological approaches may utilize methadone, naltrexone or perhaps antabuse along with drug testing, counseling, and individualized treatment plans. The Key Extended Entry Program (KEEP) in the New York City central jail is an example of a program that provides methadone maintenance to approximately 3,000 inmates annually.
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The Psychoeducational approaches are usually utilized for inmates who may not be jailed for more than three months. These approaches attempt to develop motivation and commitment to treatment from the inmate. they use techniques of self-awareness, life skills enhancement, and they provide aftercare and relapse planning. The psychoeducational approaches utilize group and individual counseling, lectures, and educational activities. A major example of the psychoeducational approach in action is the program by the Hillsborough County Sheriff's Office in Tampa, Florida. This program provides services to inmates during their last 30 days of incarceration which includes individual assessment, training in cognitive restructuring techniques, education about addiction and recovery, and vocational skills.
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Therapeutic Communities (TC's) are separate residential programs designed for the more severely drug dependent inmate. Originally developed on the Synanon model, they provide participation and fellowship in a recovering community, clear rules and sanctions, and confrontation and peer pressure to encourage a clean and sober lifestyle. While traditional therapeutic communities usually require inmate participation for 9-15 months, modified therapeutic communities may require a 6-9 month participation and a short-term therapeutic community may only be of 3-6 months in duration for the inmate. A good example of a short-term therapeutic community that can work in jails is that operated in the Cook County Jail in Chicago. Residents are pretrial inmates and spend an average of six to eight months in the program which has two phases. Phase one is about three months in a typical therapeutic community and then four months in a transition program designed to prepare the inmate to transition back into the community.
Another study of long-term therapeutic communities compares the "Stay 'N Out" TC program in the New York State Correctional System with a Milieu Treatment Program and a Counseling Program (Wexler, Lipton, & Foster, 1985). The results indicate that the TC treatment group had a significantly lower arrest rate than the other groups, followed by the Milieu Therapy Group and then the Counseling Program Group. This study also showed that time in program was related to the time until first arrest, though not to number of arrests.
An important study of long-term therapeutic communities is the Amity Righturn Substance Abuse Program where inmates spend nine to twelve months in the prison TC and then receive four months of aftercare services upon parole to the community. This model therapeutic community is considered the most ambitious demonstration program of its type that the California Department of Corrections has undertaken in 25 years (Winett, Mullen, Lowe, & Missakian 1992). Preliminary program outcomes are most positive. Inmates who were participants in the therapeutic community, but either spent less than ten months in the program or didn't leave early, such as to work furlough, experienced a significantly lower return to custody rate than the control group (23.8% vs. 38.1%). Inmates who completed the entire TC program and the four month community aftercare program had an even greater success rate (13.7% return to custody vs. 34.7% for the control; Lowe, 1992b).
While these programs demonstrate success, they must be considered as a long-term, intensive treatments which are most readily implemented in prison situations. These can also be costly treatment modalities to institute and operate. Start-up costs for the Amity Righturn program were almost $900,000 for equipment, facilities, custody staff, initial program staff costs and other first time expenditures. However, program costs per inmate in prison are expected to be only about $3,600 per year (Lowe, 1992a).
Effectiveness of Traditional Programs. There is minimal research of value on the effectiveness of traditional criminal justice drug programs (Tims & Leukefeld, 1992; Wexler, Lipton, & Foster, 1985). While some individual studies are available, programs have not been found to be effective at a level that has resulted in their general acceptance. Another problem is that it usually costs a great deal of money to implement a program and this last decade has tightened budgets throughout the criminal justice community. What money there is becomes stretched in just housing inmates rather than in implementing new programs.
For the non-criminal justice population, the Chemical Dependency/Self-Help approach is the standard treatment model that has been utilized in hospital programs nationwide for more than a decade. Also known as the "Minnesota" Model, this modality is probably the most successful community approach for non-criminal justice populations when aftercare is tied to a very strong relapse-prevention, case management, and twelve-step participation program. For criminal justice populations the evidence is less clear, especially when frequently the only part of this model that is utilized by jails may be the inhouse Alcoholics Anonymous meetings.
Programs of the Pharmacological approach are probably closest to similarity with the acupuncture protocols. Methadone, for instance, helps keep the addict heroin free so that he may be more amenable to traditional counseling approaches. However, two problems present with the methadone model. One is that methadone is also an addictive drug and the client must be detoxed from it carefully over time. The other problem is that methadone programs, like the therapeutic communities, may suffer from having participants drop out of the program prior to completion (Peters, 1993), especially when counseling methodologies are not administered along with the methadone treatment (Clark, 1990).
The Hillsborough County program, as an example of the Psychoeducational approach, demonstrated significant effects for its treatment modality upon one-year follow-up (Peters, 1993). Participants remained arrest-free longer, were arrested less frequently, and spent less time in jail than those who didn't experience the treatment modality. Yet, from the data reported by Peters, the means of the variables were so similar (as, Mean arrests of participants = 1.1 and Mean arrests of untreated inmates =1.5) and the standard deviations so large (as, SD for Mean of 1.1 = 1.1 and SD for Mean of 1.5 = 1.6) that it brings into question how meaningful these significant results may be for generalization to the jail population at large. There may be more meaning in the variable reporting that program participants stayed free of arrest for 221 days (SD = 131) while non-participants stayed free of arrest only 180 days (SD = 144; Peters, 1993).
The long-term Therapeutic Communities show promise, though they are most appropriate in prison situations, and not many prisons today have the space, staff and budget to implement these long-term programs. The shorter term therapeutic communities may be more appropriate in jails, though they suffer the same limitations of space, staff and budget that the prisons face (Peters, 1993). Another problem with therapeutic communities is that they suffer from problems of premature dropouts from treatment by inmates.
In summary, each of these four treatment approaches has demonstrated a degree of usefulness. The fact that they all require extra space to implement these programs (especially when isolated bed and activity space is required), extra full-time staff to operate the programs, and extra money to budget the programs makes it difficult for institutions to consider them as potential treatment programs. That treatment alternatives must be considered is demonstrated by the figure that 60% to 75% of untreated addicts who are paroled will return to their drug abuse within 3 months of being released and will become reinvolved in criminal activity (Lipton, Falkin, & Wexler, 1992).
ACUPUNCTURE AND CRIMINAL JUSTICE PROGRAMS
Diversion Programs. A Probation Department study in New York treated 59 offenders with acupuncture and Narcotics Anonymous meetings. Typical reports of the general population of New York probationers reveals that 79 percent typically present dirty urine tests while on probation. However, the 59 offenders tracked in the acupuncture and NA group only presented 24 percent dirty urine tests for drugs and had fewer probation revocations and re-arrests (Renaud, 1990). Another report of acupuncture treatment by the New York Probation Department showed that 68% of 55 clients attending the Lincoln Hospital Clinic as part of a pre-sentencing option responded so well to treatment that they received probation instead of receiving prison time (Smith, 1989).Officials of the Los Angeles County Health Department have recently stated that drug diversion without treatment is largely ineffective and unsuitable for offenders with serious histories of drug abuse (Sengupta, 1993).
The Miami Drug Court. Acupuncture seems to be capturing the nation's interest as each new revelation comes to light. A project of striking impact, like that of the Lincoln Hospital Clinic, is the Miami Drug Court of Dade County, Florida (Brumbaugh, 1993). The court hears only first and second offenders arrested on cocaine charges and diverts them into a three-phase treatment program. The initial phase utilizes daily acupuncture and urine testing in conjunction with traditional counseling techniques. Reports for the outcomes of the first 1,200 offenders to complete the initial phase of the program indicate that only 7 offenders were rearrested during the first six months of their treatment! Reports for the first year indicate that of 1,600 offenders treated with acupuncture, the rearrest rate was 6%, compared with the historical rearrest rate of 68% experienced prior to implementation of the drug court and acupuncture treatment program (from Brumbaugh, 1993; and Lowe, CDC, 1993). A soon to be released study of the Miami program will report that those who completed the program were rearrested less often and those who were rearrested 'stayed crime-free much longer than their counterparts' (John Goldkamp in Sengupta, 1993). In Miami the cost to incarcerate an inmate for a year in the county jail is $17,000. The Drug Court program costs about $800 per person annually.
Los Angeles is now proposing to institute a Drug Court of its own based upon the Miami model as a pilot project (Sengupta, 1993). In this jurisdiction nearly half of all criminal cases in the municipal courts are drug-related and one-quarter of all inmates in Los Angeles County jails are doing time for drug possession or sales, with many others there for other drug-related felonies.
Relapse Prevention. Recent use of relapse prevention techniques have begun to appear in criminal justice settings. These techniques may be combinations of cognitive therapies, behavioral skill training, and lifestyle change. Inmates are taught to recognize relapse triggers which may provoke drug usage and to learn new behaviors to those triggers (Peters, 1993). Acupuncture treatment given following detoxification may be used to support conventional treatment methodologies or to "immunize" against relapse. Providing acupuncture as a pre-release treatment would serve to reduce a post-acute withdrawal syndrome (PAWS) which can occur from the time following detoxification or might occur up to eighteen months following initial sobriety (Gorski, 1987). PAWS may be characterized by sleep disorders, headaches, depression, generalized malaise, listlessness, anxiety, mood swings, agitation, and intense cravings for mood altering drugs. Any of these, either alone or in combination, can become relapse triggers which may spark new bouts of drinking and drugging (Brumbaugh, 1993; Gorski, 1987; Karrell, 1990).
Some discussion and research has appeared about utilizing acupuncture specifically as a relapse-prevention modality (Karrell, 1990; Renaud, 1990), but most of the evidence has been in the form of "clinical experience", such as that reporting clients returning to acupuncture clinics months or years into recovery for "tune-ups" (Brumbaugh, 1993). A preliminary study by the team proposing this current evaluation serves as the pilot for this project. That study took place on the Honor Farm of the Santa Barbara County Jail and made auricular acupuncture available to 51 inmate volunteers, 85% of whom reported a history of alcohol or other drug abuse. Results from this study indicate that inmates who received 24 or more acupuncture treatments during their last 30 days of incarceration were two-thirds less likely to be rearrested in the 2 months following release than those having 6 or fewer acupuncture treatments during their last 30 days (Brumbaugh & Wheeler, 1991).
Smith (1989) makes the distinction between severely addicted abusers and those who have more abstinence and suggests that the NADA five-point auricular acupuncture protocol would be most effective on practicing addicts or those very close to their addiction. Sherwood (1993), a practitioner of oriental medicine, emphasizes that once the chemical addiction itself is treated, underlying pathology is permitted to surface. If the symptoms of this pathology are not treated, such as headaches, anxiety, and depression, then the addict is set up for relapse from post-acute withdrawal syndrome. Sherwood suggests that using a modified NADA technique (MNT) utilizing four of the five NADA ear points and from one to four additional body points to treat additional symptoms reported by addicts who are already detoxified, would provide a greater barrier to relapse by treating the physiological relapse triggers.
Acupuncture as an adjunct to treatment. Brumbaugh (1993) emphasizes that acupuncture must be utilized along with the traditional treatment modalities as an adjunct to complement and enhance treatment. Renaud (1990) also states that acupuncture must be part of a complete program. In a study commissioned by the State of California, the Bay View Hunter's Point acupuncture versus methadone detoxification study was conducted without traditional counseling methodologies. The results show that a greater number of participants obtaining acupuncture completed the program and detoxified in half of the time than the methadone group and at half of the cost. However, failure for either group to demonstrate long term abstinence is attributed to the lack of intensive counseling, lack of frequent urine testing and lack of social support in the form of self-help groups. Their recommendation was that acupuncture be included as an adjunct to treatment, rather than to be considered the treatment itself (Clark, 1990; Lois Lowe, California Department of Corrections). Thus, when acupuncture is used to complement individual and group counseling, drug testing, Twelve-Step programs, and appropriate medications, the results may be very impressive, but when used in isolation and not with traditional techniques the results may be short-term.
This Literature Review was written by Dr. Martin Rickler of The Paladin Group in 1993 for a research proposal and is presented here with the hopes that it will provide useful treatment information for the criminal justice community. Recently Dr. Rickler wrote the proposal which brought $714,000 in federal funds to Santa Barbara, California for a Substance Abuse Treatment Court (Drug Court). Dr. Rickler also wrote the renewal proposal which provided an additional $250,000 in funding for the Santa Barbara Drug Court.
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