Regular article

Acupuncture treatment for opiate addiction: A systematic review

James B. Jordan, (Ph.D.)
4
Graduate School of Counseling Psychology, University of Maryland University College, Okinawa, Japan
Received 11 February 2006; accepted 20 February 2006
Abstract
A review of the efficacy of acupuncture as treatment for opiate addiction, covering 33 years of reported literature in western
scientific journals, was systematically undertaken. Some abstracts from Chinese language journals were also briefly reviewed. Supportive
evidence often came from noncontrolled nonblinded methodologies. When well-designed clinical trials (randomized, controlled, single-
blind methodologies) were used, there was no significant evidence for acupuncture being a more effective treatment than controls.
Some of the current supportive evidence for efficacy came from Chinese journals that have not been translated into English yet.
D 2006 Elsevier Inc. All rights reserved.
Keywords: Acupuncture treatment; Opiate addiction; Alternate therapies; Drug treatment; Heroin; Substance abuse treatment
1. Introduction
Acupuncture has a long history in China as a panacea
for illnesses. In the past 33 years, it has been reported in
mostly western literature reviews under many topics of
medical research, such as pain control (Arita, Hayashida,
& Hanaoka, 2004; Eshkavari & Heath, 2005; Mendelson
et al., 1983) in fibromyalgia (Assefi et al., 2005), head-
aches (Melchart et al., 2005), and Parkinsons disease (Tan,
Lau, Jamora, & Chan, 2005). In psychology, acupuncture
has recently been studied for the treatment of depression
(Allen, Schnyer, & Hitt, 1998; Du, Li, Yan, Zhang, &
Huang, 2005; Ernst, Rand, & Stevinson, 1998; Jorm,
Christensen, Griffiths, & Rodgers, 2002; MacPherson,
Thorpe, Thomas, & Geddes, 2004), alcoholism (Smith &
ONeil, 1975), cocaine addiction (Avants, Margolin,
Chang, Kosten, & Birch, 1995), and schizophrenia
(Rathbone & Xia, 2005).
For some westerners, acupuncture is seen as a quick,
inexpensive, and relatively safe form of treatment for
addictions (DAlberto, 2004). But is this treatment effec-
tive? The purpose of this article is to draw conclusions,
based upon the 33 years covered in the literature, as to
whether acupuncture is an effective treatment for opiate
addiction. There are many reviews of acupuncture, but there
are few controlled clinical studies. Methods and research
designs have been issues of debate among acupuncture
clinicians and researchers (Margolin, Avants, & Kleber,
1998). Other issues are as follows: the validity of previous
research studies that did not control subjects with random-
ized assignment, the use of specific point locations for
needle insertion, the degree of blinding among research
subjects, and bias checks.
2. Traditional diagnostic process
The ancient theory of traditional Chinese medicine was
first recorded in the bYellow Emperors Classic of Medicine,Q
the oldest known book about Chinese medicine and one of
the earliest known medical texts (also known as bPlain
Questions and the Canon of AcupunctureQ) that was compiled
sometime before 200 BC. The book was a summary of
medical ideas and techniques on medical anatomy and
physiology of the previous millennia (Hu, 2004).
Traditional Chinese medicine is based on the concept of
the flow of energy or Qi (bchiQ) through meridian pathways
in the body. A decision for intervention is based on a
0740-5472/06/$ see front matter D 2006 Elsevier Inc. All rights reserved.
doi:10.1016/j.jsat.2006.02.005
4 UMUC-Asia, Graduate Office, Bldg 5679, Room 11, Butler-kichi,
Ginowan-shi, Okinawa-ken 901-2200, Japan. Tel.: +81 98 958 4678.
E-mail address: jjordan@asia.umuc.edu.
Journal of Substance Abuse Treatment 30 (2006) 309314
diagnosis by pulse, and a conceptualization of the strengths
and weaknesses is made within the concept of five
elements (Hu, 2004). Qi flows through each of the 12
main meridians, which represent a major organ system, and
on these meridians are 365 acupuncture points. When yin
and yang are out of balance, Qi becomes blocked, leading
to illness. Diagnosis depends upon what is perceived to be
out of balanceusually an excess of yin or yang
energiesas all meridian points are associated with yin
and yang. Usually, a three-level pulse diagnosis on the
wrist related to the bodys major organs is performed; an
eye diagnosis looks at the quality of the iris and at the
sclera for discoloration; a cursory physical examination,
usually visual only, assesses overall health and weight/
muscle mass distribution. This is the traditional protocol,
and other Asian countries have adopted variations to this.
bOriental diagnosisQ was popularized in the west during the
early 1970s by Japanese Nyoiti Sakurazawa (aka George
Oshawa) and Michio Kushi (Tara, 1976). The western
concept of homeostasis is another way of viewing the
traditional Chinese medicine diagnostic process.
Both China and the west have been diligently putting this
ancient healing technique under the scrutiny of scientific
analysis. Acupuncture needles hooked up to a very mild
electrical current, known as electroacupuncture, has also
emerged as a trend (Cai, 1980; Choy et al., 1978).
The earliest reports looked at ways to explain the
acupuncture phenomenon to western scientists. Two studies
(Gunn, Ditchburn, & King, 1976; Matsumoto & Lyu, 1975)
reported a high correlation between acupuncture point loci
and peripheral nerve location. Brewington, Smith, and
Lipton (1994), in their review, summarized that several
researchers (e.g., Bergsman & Wooley-Hart, 1973; Brown,
Uleh, & Stern, 1974; Reichmanis, Marino, & Becker, 1976;
Rosenblatt, 1981) concluded that acupuncture points are
anatomically unique points of low impedance on the skin
and can be located with a sensitive ohm meter; in addition, it
has electrical potential higher than those of surrounding
areas (Wensel, 1980, as reported in Brewington et al., 1994).
3. Materials and methods
A keyword search was conducted utilizing the EBSCO
search engine through the University of Maryland Univer-
sity Colleges online library resources. The keyword search
was conducted in January 2006 using the following data-
bases: Academic Search Premier, CINAHL, ERIC, MED-
LINE, PsycARTICLES, PsycBOOKS, PsycEXTRA,
Psychology and Behavioral Sciences Collection, and Psy-
cINFO. No dates were used as limiting parameters. Two
keyword searches were used and checked against each
other. The keywords in the first search were bacupunctureQ
in all default fields AND bopiateQ in all default fields. The
second search used bsubstance abuse treatment Q and
bacupuncture.Q Comments and replies were not included;
only review articles and clinical trials were reviewed. Past
review articles are briefly summarized here, but the main
body is based upon clinical trials.
4. Results
4.1. Issues in acupuncture treatment
Acupuncture has historically been used for just about
everything. But more recently, western scientific method-
ology has appeared in acupuncture research in several
countries such as Singapore (for a host of treated diagnoses
such as Parkinsons disease; Tan et al., 2005), Denmark
(for the treatment of postpartum depression; Rosted &
Jorgensen, 2005, Danish abstract only), and Japan (for
effective treatment of chronic pain; Arita et al., 2004).
Some of the wide research applications of acupuncture
include the following: variability in clinical response, where
analgesic tolerance has been identified as a likely limitation
(Chevlen, 2003); the need for a common treatment protocol
based upon traditional Chinese medicine, as has been made
with the National Acupuncture Detoxification Association
protocol (DAlberto, 2004); and context of treatment in
determining differences in outcome measures (Margolin,
Avants, & Holford, 2002).
Brewington et al. (1994), in their review, reported that
previous research (e.g., Patterson, 1974, 1975, 1976; Wen &
Cheung, 1973a, 1973b, 1973c) breported that electrical
stimulation appeared crucial in alleviating withdrawal dis-
tress with substance abusers, and that needle insertion and the
use of traditional acupuncture point locations were also not of
critical importance in alleviating withdrawal symptoms.
Empirical evidence supporting this claim has apparently not
been publishedQ (p. 290).
According to a review by Clayton (2005), in general,
meta-analyses have not demonstrated a significant efficacy
of complementary and alternative medicine therapies:
pharmacological and biologic treatments such as herbal
therapies; dietary supplements; natural hormones; health
and healing practices such as hypnosis, meditation, yoga,
biofeedback, exercise, and chiropractic or massage therapy;
and nontraditional medical systems such as acupuncture.
4.2. Adverse events of acupuncture
In a review of the research literature, Ernst and White
(2001) determined the range of incidence of adverse events
associated with acupuncture. The results were not uniform,
but the most common adverse events were needle pain
(145%) from treatments, tiredness (241%), and bleeding
(0.0338%). Fainting and syncope were uncommon, with
an incidence of 00.3%. Feelings of relaxation were
reported by as many as 86% of patients. Pneumothorax
was rare, occurring only twice in nearly a quarter of a
million treatments. Their conclusions were that, although the
J.B. Jordan / Journal of Substance Abuse Treatment 30 (2006) 309314 310
incidence of minor adverse events associated with acupunc-
ture may be considerable, serious adverse events are rare.
4.3. Accurate application
Another issue in acupuncture treatment has been the
accuracy of meridian points used in scientific research,
leading to confounding results for acupuncture research. The
first study by Brown et al. (1974) reported only techniques
for location. Recently, several authors from South Korean
universities (Yin, Park, Seo, Lim, & Koh, 2005) evaluated
two traditional methods of point location: directional (F-cun)
and proportional (B-cun). These are collectively called the
cun measurement system. They suggest that differences in
results may depend upon racial physiological differences
between Europe and Asia, as measurement is based upon the
length of an individual practitioners index finger joint
length in B-cun. Their conclusions were that the F-cun
method is unreliable and that further research should be
conducted to determine a more accurate point-locating
method primarily based on the B-cun method.
4.4. Drug addictions
The earliest writers in western-oriented professional
journals on acupuncture for the treatment of substance
abuse were Wen and Cheung (1973a, 1973b, and 1973c).
They reported that acupuncture alleviated withdrawal
symptoms in an opiate-dependent patient treated with
electroacupuncture while undergoing surgical analgesia
for another disorder. But, in the history of narcotic
withdrawal treatment, there have been many bcuresQ
enthusiastically received and then quietly dropped after
turning out to be either ineffective, dangerous, or both
(Kleber & Riordan, 1982).
Today, acupuncture treatment is almost always in
conjunction with drug counseling. Previous reviews (e.g.,
Moner, 1996) were supportive of acupuncture as a safe
effective treatment for addictive diseases with opiates,
alcohol, cocaine, and nicotine. Auricular acupuncture is
the most common form of acupuncture treatment for
substance addiction in both the United States and the UK
(DAlberto, 2004; Margolin, 2003; Margolin et al., 2002);
auricular acupuncture is the bilateral insertion of needles in
the outer ears.
4.5. Evidence for acupuncture as treatment for
drug addiction
Early research began by looking at the phenomenon of
the analgesia effects of acupuncture that demonstrated
similarity to those of endorphins and enkephalins (Chapman
& Benedetti, 1977; Clement-Jones et al., 1979; Pomeranz &
Chiu, 1976).
According to Severson, Markoff, and Chun-hoon (1977),
the first clinical report of acupuncture for the detoxification
of heroin- and opium-addicted patients in the professional
literature was the study of Wen and Cheung (1973b), which
was carried out in Hong Kong. Severson et al. performed a
follow-up project in Hawaii under the supervision of Wen.
The clinical trial had a small sample and had limited
success. The methodology did not include the blinding of
subjects, or a control group. bOf the eight patients, five were
detoxified successfully; one elected to leave the hospital
before detoxification was finished, and two had poor relief
of symptoms and were switched to methodone-assisted
detoxificationQ (p. 915).
There is evidence on both sides of the fence regarding the
efficacy of auricular acupuncture treatment for drug-addicted
patients. Some research studies support the viability of the
method (Avants et al., 1995; Gurevich, Duckworth, Imhof, &
Katz, 1996; Margolin et al., 1998; Timofeev, 1999), whereas
others cast doubts (Bullock, Kiresuk, Pheley, Culliton, &
Lenz, 1999; Otto, Quinn, & Sung, 1998).
Avants et al. (1995) laid the methodological foundation
for research in acupuncture treatment for cocaine-addicted
(and opiate-addicted) patients. They conducted a 6-week
single-blind study of acupuncture for cocaine dependence in
methadone-maintained patients (N = 40) to identify an
appropriate needle puncture control for use in future large-
scale clinical trials. They found an overall positive response
to treatment on a variety of drug-related and psychosocial
measures. Among cocaine-addicted patients, abuse decrea-
sed significantly for patients, and the only statistically
significant difference between the two types of needle
puncture used was on ratings of craving. They went on to
suggest that very large sample sizes would be required to
detect treatment differences between the control condition
and active acupuncture.
Otto et al. (1998) performed a pilot study on auricular
acupuncture as an adjunctive treatment for cocaine addiction
and found no significant difference between treatment and
control groups. They did point out that the patients, as a
whole, remained in treatment longer than a retrospectively
analyzed group that received no acupuncture.
Looking at electroacupuncture, one of the earliest
researchers to use this technique in methadone withdrawal
was Gomez and Mikhail (1978). At times, opiate and
electroacupuncture research included two treatment varia-
bles, which made it difficult to sort out differences (e.g.,
Kroening & Oleson, 1985). In addition, Cai (1980)
demonstrated that strong pain consists of sensory and
emotional components, both of which can be influenced
by electroacupuncture; in addition, Cai found that electro-
acupuncture has an analgesic effect on both components,
but the effect is more marked in emotional components. But
others questioned electroacupuncture and the predetermined
classic Chinese acupuncture treatment by looking at
objective criteria to define points for needle insertion in
cocaine-abusing subjects. Margolin, Avants, Birch, Falk,
and Kleber (1996) did not recommend the use of electrical
devices for point determination. They felt that there was
J.B. Jordan / Journal of Substance Abuse Treatment 30 (2006) 309314 311
little scientific basis for the preselection of specific points
for needle insertion within auricular zones (especially with
the difficulty of accurately measuring electrical resistance at
ear points), and that needle placement should be based upon
clinical judgment. This was one of the first clinical trials of
auricular acupuncture for cocaine addiction, and they
articulated specific zones of needling (Shenmen, liver, lung,
and sympathetic), in addition to proposed control zones
(located on the ear helix).
Montazeri, Farahnakian, and Saghaei (2002) looked at
the use of acupuncture on acute withdrawal symptoms of
rapid opiate detoxification (ROD). They argue that ROD is
among the best treatments for substance abuse, but that,
unfortunately, this method is associated with severe with-
drawal reaction. In their small study of 40 adult male
subjects addicted to opioids and scheduled for ROD by
naloxone, they found that the severity of withdrawal
reaction, as measured by the Clinical Institute Narcotic
Assessment score, was significantly lower in their acupunc-
ture group. They concluded that body acupuncture reduces
the severity of withdrawal symptoms associated with ROD.
They recommended that this nonpharmacological method of
treatment be included in future ROD programs.
In a brief review of an English abstract summary written
in a Chinese-language-only journal (Zhongguo Zhen Jiu),
there is one particular study that appears to add to the
evidence in support of acupuncture as a substance abuse
treatment. In a large study, Wen et al. (2005) looked at the
clinical application of acupuncture on 220 subjects for the
treatment of heroin withdrawal syndrome. Their objective
was to make a technical standard for acupuncture manip-
ulation in the treatment of heroin withdrawal syndrome. One
group was treated with acupuncture, and a control group
was given an oral administration of lofexidine hydro-
chloride. In a prepost acute withdrawal stage method, the
acupuncture treatment group bhad a satisfactory, rapid, safe,
and reliable clinical therapeutic effect, as measured by total
withdrawal symptomsQ at different time intervals, at differ-
ent degrees of insomnia reported, and in Hamilton Anxiety
Scale scores. However, one has to ask: Is this study
equivalent to the Margolin et al. (2002) study that did not
find significant evidence for acupuncture as a more effective
treatment for opiate-addicted patients? Until we are able to
translate the study of Wen et al. and several others (e.g., Mu,
Liu, Hu, & Xu, 2005; Wen et al., 2005; Wu, Cui, & Han,
1995), there will be doubt.
4.6. Evidence against acupuncture as treatment for
drug addiction
Bullock et al. (1999) performed a single-blind, random-
ized, placebo-controlled study to evaluate auricular acu-
puncture in the treatment of cocaine addiction. Their study
had 236 residential and 202 day treatment clients. Treatment
group subjects received acupuncture at three ear points
considered specific for the treatment of substance abuse.
They did not find any significant treatment differences
between true and sham acupuncture, and their control
psychosocial groups. They also found no differences among
the three dose levels of true acupuncture.
Margolin et al. (2002) gave the best evidence against the
use of acupuncture as treatment for drug addiction. They
demonstrated in a clinical trial that auricular acupuncture
treatment for cocaine- and opiate-addicted patients is neither
a stand-alone treatment nor of great benefit. In a compre-
hensive study that contained two-thirds cocaine-only-
dependent subjects and one-third cocaine/opiate-dependent
subjects (receiving methadone treatment), Margolin et al.
put a cap on the issue and on the methodological problems
previously reported. This was a follow-up to a previous
smaller study (Avants, Margolin, Holford, & Kosten, 2000)
by primary researchers at Yale University. This large well-
designed study (a randomized, controlled, single-blind
clinical trial conducted from November 1996 to April
1999) found no significant evidence for acupuncture being
a more effective treatment than controls. The controls
consisted of neutral needle insertion and relaxation techni-
que. Their conclusion was that auricular acupuncture
treatment does not warrant a stand-alone treatment for
cocaine or opiate addiction (i.e., one third of their subjects).
In addition, a review of six acupuncture trials conducted
by DAlberto (2004) could not confirm acupuncture to be an
effective treatment for cocaine abuse (alone). DAlberto
reviewed several databases to answer the question: bIs
acupuncture effective in the treatment of cocaine addiction?Q
DAlberto made sure to exclude some parallel forms of
treatment that also use acupuncture meridian theory, such as
moxibustion, laser acupuncture, transcutaneous electrical
nerve stimulation, and electroacupuncture. The review
focused only on people addicted to cocaine (their main
addiction) and on needle acupuncture, either in a single-
blind or a double-blind process, using randomized subject
procedures and a reference group incorporating a form of
sham points. The results found a relatively adequate
methodology quality in clinical trials, but did not yield a
statistically significant association.
5. Discussion
Acupuncture treatment does not demonstrate the type of
qualitative and quantitative research needed to validate its
efficacy in the treatment of opiate-addicted (or cocaine-
addicted) patients. An explanation of past reports on the
positive, albeit limited, effects of acupuncture with addicted
patients probably was due, in large part, to synergistic
placebo effects. Whatever other treatments were ongoing at
that time, such as counseling, treatment milieu, or support
groups, probably provided some of the positive outcomes.
This conclusion comes from the lack of controls in
supportive clinical trials, where other variables such as
counseling and milieu were not methodologically controlled.
J.B. Jordan / Journal of Substance Abuse Treatment 30 (2006) 309314 312
This author speculates that, with the addition of exotic (to
westerners minds) acupuncture treatment, a certain placebo
effect synergized with other modalities, and the result was a
limited positive effect. One should not underestimate the
power of placebo in working toward humans capacity for
recovery. However, when well-run methodologically sound
studies are painstakingly administered, the placebo effect
becomes apparent and the minimal efficacy of acupuncture
in opiate addiction can be demonstrated.
As far as recommendations go, the author agrees with
Carol and Rounsaville (2003), who point out the glaring
problem in substance abuse research: Behavioral treatments,
for which there is strong empirical support, have rarely been
implemented in clinical settings. This is partly because a
reductionistic behavioral approach does not typically work
with a diagnosis per se, but rather with a specific defined
behavior. In addition, part of the problem is that a behavior
can occur in the context of several diagnoses, as well as
before, during, and after any given treatment. There needs to
be a cognitive component to the behavioral approach to
articulate an association with pathological epidemiology.
After 33 years of active research by both Asian and
western scientists, the evidence is just not there to support
acupuncture as a central treatment for opiate or any other
drug addiction. Supportive research that continues to come
from China needs to be translated to see if the methodology
is equivalent to western nonsupportive research. Therefore,
the conclusions of the clinical trials in this review are
limited to English professional journals.
In order for a new treatment to be accepted and marketed,
there needs to be robust scientific research with successive
positive outcomes. When Prozac (fluoxetine; Eli Lilly and
Co., Indianapolis, IN) hit the market, it quickly took off,
developing into a panacea; despite some minor setbacks, it
continues to be an important viable solution in many
psychiatric treatment regimens. It is what is demanded,
and acupuncture has not delivered in this specific area of
treatment. It may be that, in addition to a placebo effect, the
positive outcomes from China may be due to the treatment
of some of the symptoms alone, seen through Taoist
principle viewpoints and not through the western DSM-IV
full diagnostic criteria worldview.
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