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Bearn J., Swami A., Stewart D. et al.,
Journal of Substance Abuse Treatment: 2009, 36, p. 345–349.
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From south London, one of only a handful of randomised studies trialling acupuncture for opiate detoxification adds to the accretion of 'ineffective' verdicts, raising the question of why the treatment continues to be popular.
Summary The issue addressed in the study was whether supplementing a standard inpatient methadone-based detoxification with acupuncture would 'add value' by further relieving craving and the severity of withdrawal symptoms. Standard treatment at the specialist unit in London was based on stabilisation on methadone then reducing doses over 10 to 14 days. Total stays were intended to last four weeks. For the study, 82 opiate dependent patients provided data Another 11 were randomly allocated but later withdrew their consent to participate in the study. after being randomly assigned to receive ear acupuncture Treatment was administered by qualified acupuncturists, trained to the same national standards, from the Gateway Clinic, the only traditional Chinese medicine clinic in the UK funded by the National Health Service to treat drug addiction. daily for two weeks during their stay, or instead to undergo a similar procedure involving attaching clips to the ear. Patients were told that this too was an active treatment, though as far as was known it did not have nor was it intended to have any impacts on withdrawal severity or craving. Daily measures of withdrawal severity and craving were taken using standard questionnaires. Urine screening was used as an objective assessment of treatment adherence. On none of the 14 days nor over the entire fortnight were there statistically significant differences between patients allocated to 'real' acupuncture and the 'sham' treatment. Such statistically insignificant differences as there were favoured the 'sham' treatment, in the last few days of which patients experienced slightly less intense craving and withdrawal symptoms than acupuncture patients during the same period. The authors commented that the results are consistent with the findings of other studies which failed to find any effect of acupuncture in the treatment of drug dependence. They expressed concern that despite negative research findings, acupuncture continues to be widely seen as an effective intervention by workers and patients.
commentary This is one of only a handful of randomised studies trialling acupuncture for opiate detoxification. Lack of impact is particularly disappointing as if anything the circumstances favoured The acupuncture option was the procedure the acupuncturists had been trained in and taught was effective. Any unintended signals they transmitted to patients would presumably have been indicative of their faith in that treatment and lack of faith in the alternative. Some patients too would probably have seen acupuncture as a bona fide treatment. In contrast, in this study the alternative may not have been seen as a convincing therapy. If anything, such influences would tend to have raised patients' expectations of the effectiveness of acupuncture relative to the alternative, giving it a head start in actual effectiveness. the 'real' protocol. Like the featured study, previous studies of acupuncture in the treatment of opiate addiction have been unconvincing, leading a reviewer to conclude that such positive findings as there have been were due to placebo effects. What seems to have been the only previous randomised trial of acupuncture for opiate detoxification available in English was conducted in an outpatient clinic in San Francisco. In a programme with dramatically poor retention in either of the studied treatments, retention was nevertheless significantly improved by assigning patients to recommended ear acupuncture as opposed to a similar, but non-recommended, 'sham' procedure. However, by the last week of the three-week treatment period there was no difference in known Negative urine tests with missed tests treated as positive. heroin abstinence rates, which in both cases were around a very poor 7%. Even in respect of improved retention, it is impossible to exclude Care was taken to avoid the acupuncturist (who knew which was the real and which the sham treatments) influencing the outcomes but this could not entirely be eliminated. Also the locations on the ear used for the the control condition were identified by the lack of a tingling/heat sensation when touched, the real ones by the presence of such a sensation, perhaps an implicit message to patients that these were active sites. the possibility that this was due to patients' awareness of which was intended to be the active treatment. A second randomised study available only as an abstract found that prior body acupuncture attenuated the increase in withdrawal severity after rapid detoxification using an opiate antagonist. It seems that no 'sham' treatment was used as a comparator, leaving the possibility that simply doing something in the lead up to the detoxification which patients expected to make them more comfortable was the active ingredient, rather than acupuncture itself.
The 'ineffective' verdict on acupuncture extends to the treatment of cocaine dependence, while an attempt to replicate earlier positive findings in the treatment of alcohol dependence using a more definitive research design found no benefits in terms of drinking reductions and worse retention. Overall an exhaustive search for relevant studies concluded that there was little evidence that acupuncture improved alcohol treatment completion or outcomes.
These studies concerned patients already attracted to treatment and generally compared real acupuncture to a pretend but still convincing alternative. The possibility remains that offering something concrete like acupuncture helps attract people to services, and that doing something both clients and staff believe is worthwhile (even if it is a 'sham' procedure) helps retain patients in treatment, and in doing so could improves outcomes. Just such a role was specified Complementary therapies were defined as “Any non medical intervention which regardless of therapeutic value enhances client access and retention in services, such as auricular acupuncture.” in recent guidance from the National Treatment Agency for Substance Misuse on treatment intervention costing and on treatment systems. Such considerations may explain why despite no convincing evidence of efficacy, acupuncture continues to feature in many of the treatment plans As revealed in March 2009 by a search for term 'acupuncture' on the web site of the National Treatment Agency for Substance Misuse, http://www.nta.nhs.uk. developed by local partnerships responsible for commissioning services in England.
Thanks for their comments on this entry in draft to Jennifer Bearn, Michael Gossop and John Witton of the National Addiction Centre in London and Russ Hayton from the Plymouth Drug and Alcohol Action Team. Commentators bear no responsibility for the text including the interpretations and any remaining errors.
Last revised 14 August 2009
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