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Cho S-H, Whang W-W.
Alcoholism: Clinical and Experimental: 2009, 33(8), p. 1305–1313.
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An exhaustive multi-country and multi-language trawl for randomised trials of acupuncture in the treatment of alcohol dependence found just 11 studies which overall offered little support for any form of the therapy.
Summary Acupuncture has been used in the treatment of substance-related disorders for the past 30 years. However, there has not yet been a systematic review to assess the effectiveness of various types These is a German-language review relating to auricular acupuncture. See http://direct.bl.uk/bld/PlaceOrder.do?UIN=152361543&ETOC=RN of acupuncture in the treatment of alcohol dependence. The present review aimed to fill this gap by analysing results from trials which randomly allocated alcohol dependent patients to any type of acupuncture versus a comparison (or no) treatment. To find the studies the authors searched 19 electronic databases (including English, Korean, Japanese, and Chinese databases) for studies in any language published up to June 2008, as well as manual searching relevant journals, symposia, and conference proceedings.
The search found 11 such studies involving 1110 participants, of which just two satisfied all the review's methodological quality standards. In relation to the primary outcomes assessed by the trials, six found no significant advantages for acupuncture. Among the three trials to report these, adverse side effects were mostly minimal.
Eight of the trials reporting relevant data compared 'real' acupuncture with either a sham or placebo procedure which simulated real acupuncture but was not intended to be an active treatment. Of the five trials which assessed this, two found a significant impact on craving for alcohol, but one was available only in abstract form and the other was able to follow-up only a minority of patients. Of the two studies which looked at this, neither reported an effect on withdrawal symptoms. Treatment completion rates were improved by real acupuncture in one of five studies. However, when the results from all five were combined in a meta-analysis, A study which uses recognised procedures to summarise quantitative results from several studies of the same or similar interventions to arrive at composite outcome scores. Usually undertaken to allow the intervention's effectiveness to be assessed with greater confidence than on the basis of the studies taken individually. there was no overall advantage for real versus simulated acupuncture.
Among the five studies which tested acupuncture as a supplement to conventional treatments, three of four found reduced craving for alcohol. Just one study of five reported an improved treatment completion rate and when results from all five were combined, there was no statistically significant improvement in completion rates among patients allocated to supplementary acupuncture.
A further study compared acupuncture with aromatherapy and found no significant differences in craving or withdrawal symptoms.
The conclusions the authors could draw were limited by the poor methodological quality and the limited number of the trials. Overall their results did not support the use of acupuncture for the treatment of alcohol dependence. In particular evidence was lacking that 'real' acupuncture actually conferred any benefits compared to a simulated procedure. As a supplement to conventional therapies, there were promising findings indicating that acupuncture can reduce craving for alcohol.
commentary This review is particularly valuable for its rigorous approach and its exhaustive multi-country and multi-language trawl of the relevant research. It shows that the limited research to date has been unable to demonstrate consistent benefits, except perhaps in relieving craving during treatment. The pattern of findings suggests that if there are any benefits from acupuncture, they are caused not by the intended mechanisms, but by non-specific factors such as extra therapist contact time or the placebo effect of receiving what seems to be an active therapy. The featured review's 'unproven' verdict for the treatment of alcohol dependence follows similar verdicts in respect of the treatment of dependence on opiates, and on cocaine using auricular acupuncture.
The inadequacy of the evidence for a specific effect of acupuncture also however applies to some recognised psychosocial therapies, which are held to a lesser standard for demonstrating their efficacy. In many of the studies acupuncture is tested to the same standard as medications, using a (to the patient) indistinguishable simulation as the comparator. This research design gives the comparator treatment the full benefit of the placebo effect and other non-specific therapeutic influences, making it difficult for 'real' acupuncture to further improve outcomes. Such rigorous testing is not possible for psychosocial therapies, which are generally tested against either no therapy or a clearly different alternative. The difference the comparator can make is clear for example in respect of cognitive-behavioural therapies, which record a much greater advantage when compared to no treatment than when compared to an active alternative therapy. None of the studies analysed in the featured review compared acupuncture to no treatment at all. When the comparator was merely treatment as usual, there appeared to be some benefits in terms of reduced craving. When the potential for a placebo effect was elevated by simulated acupuncture, the real version was less able to demonstrate benefits.
Despite these findings, the possibility remains that offering something concrete like acupuncture (even if it is a 'sham' procedure) helps attract people to services. Some studies have also suggested that doing something both clients and staff believe is worthwhile can help retain patients in treatment. If this is the case, acupuncture could indirectly improve outcomes by increasing the patient's exposure to treatment's active ingredients. 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 treatment services in England.
Last revised 15 August 2009
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