Acupuncture heroin detoxification: a single blind clinical trial

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Acupuncture heroin detoxification: a single blind clinical trial.

Washburn AM, Fullilove RE, Fullilove MT et al. (1993)

Journal of Substance Abuse Treatment. 10(4): 345-51

This study was carried out in San Francisco at the Bayview-Hunter's Point Foundation, "a non-profit human services agency". The aim of the study seems to have been to determine if acupuncture has an effect on perseverance in attending for treatment. One hundred heroin addicts (we are not told whether any diagnostic criteria were used) who met the selection requirements: history of intravenous use of heroin confirmed by physical examination for signs of recent needle use, and not currently enroled in a methadone detoxification programme, were recruited. Clients were excluded if pregnant, on probation or on parole. Informed consent was obtained and the recruits were randomised to the standard treatment group (n=55) or the sham group (n=45).

The standard treatment involved insertion of disposable acupuncture needles at sympathetic, shen men, lung and kidney ear points. The acupoints were located anatomically and by the client reporting a tingling or hot sensation when points were touched with a blunt instrument. We are not told whether needles were inserted bilaterally. The sham group had acupuncture needles inserted at four ear points that were not thought to be specific for addiction. We are not told what these points were, except that they were geographically close to the standard points. Needles were left in for 20-45 minutes. Both groups were treated together in a large room. Acupuncture was given daily for 21 days. In addition to acupuncture, both groups received an entrance physical examination, counselling, discharge planning and AIDS education. On the first day, and weekly thereafter, withdrawal symptoms were assessed with a checklist and urine samples were collected. Patients were paid 20 dollars at the start and 5 dollars per urine sample collected.

Results

The two groups were comparable by the usual demographic characteristics. Scores on the withdrawal symptoms instrument (we are not told which instrument was used) were 35.8 and 31.9 for the standard and sham group respectively. These scores were not significantly different. A figure which shows the percentage of clients attending per group during the treatment period shows that initially there was a dramatic decrease in attendance in both groups, but that the sham group appears to have fared worse both at the start and during the treatment period. Unfortunately there is no mention whether the difference between the groups illustrated in this figure is statistically significant.

Table 2 compares the two treatment groups on three additional measures of attendance: median number of days in treatment, median last day (of 21 ) and number of subjects staying in treatment beyond 21 days. The median number of days in treatment was 2 for the standard group and 1 for the sham group. Sixteen subjects in the standard group and 4 subjects in the sham group stayed on with the programme after the end of the trial period of 21 days (P<0.05). Table 3 lists the "Mean number of days in treatment by treatment condition and self-reports of frequency of heroin use in the 30 days preceding entry into the study". The subjects were grouped according to the frequency of their use of heroin: light use (once daily or less), medium use (2 to 3 times daily) and heavy use (more than 3 times daily). Table 3 shows that there were more light users in each group than heavy users. At intake only 46.5% sham and 61.1% standard tested positive for opiates. In the second week a mere 4 samples (2 positive) from the sham group and 17 samples (11 positive) from the standard group were collected. In the third week 1 out of the 4 sham group samples and 5 out of 9 standard group samples were positive.

The conclusion was that the standard ear acupuncture produced a significant effect in terms of continuing attendance for treatment when compared to acupuncture at non-standard points. Lighter users of heroin were more likely to attend than heavier users. Standard acupuncture clients were more likely to return for additional treatment after the 21 days than the sham group. The authors comment on the limitations of their study and state that they would have liked to have conducted a double blind trial, although I am not sure how they were planning to do this. Addicts probably volunteered for the financial inducement paid at the start of the trial, resulting in the high initial drop out rate. Only 53% of study subjects tested positive for opiates at intake, which is probably a reflection of the lack of strict diagnostic criteria for drug dependence and abuse on entry to the trial.

Comments

The authors have demonstrated that auricular acupuncture at points thought to be specific for addiction (shen men, sympathetic, lung and kidney) results in patients utilising the treatment service better than those who did not receive specific acupuncture. This is a useful finding because the management of substance abuse is far from satisfactory and anything that can help to retain these patients in a treatment programme is valuable.

This study would have been more acceptable if the authors had included a control group receiving only the usual treatment. Although the authors did classify the subjects according to their pretreatment level of heroin use, no attempt was made to use the amount of heroin consumed as an outcome measure. "While the study reported here found a treatment effect in terms of retention for subjects assigned to the standard acupuncture condition, we have no evidence that even those who completed the 21 day programme detoxified from heroin". If acupuncture were shown to result in reduction of heroin consumption then clearly it would have major implications for the treatment of heroin addicts. There is scientific rationale as to how acupuncture may be useful in the treatment of opiate addicts and indeed the authors refer to this. However, it is essential to measure in some way whether the goal of treatment, detoxification, has been achieved. It is encouraging to see randomised trials being carried out in this area, but clearly more research is necessary.

Article copyright The British Medical Acupuncture Society.

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By Hagen Rampes

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