Exploring the Multiple Roles of Acupuncture in Alleviating the Opioid Crisis.

Abstract

The Journal of Alternative and Complementary MedicineVol. 24, No. 4 Sar Turning PointsFree AccessExploring the Multiple Roles of Acupuncture in Alleviating the Opioid CrisisJiang-Ti KongJiang-Ti KongSearch for more papers by this authorPublished Online:1 Apr 2018https://doi.org/10.1089/acm.2018.0083AboutSectionsPDF/EPUB Permissions & CitationsPermissionsDownload CitationsTrack CitationsAdd to favorites Back To Publication ShareShare onFacebookTwitterLinked InRedditEmail Jiang-Ti Kong, MDDivision of Pain MedicineDepartment of Anesthesiology, Perioperative and Pain MedicineStanford University School of MedicinePalo Alto, CAEditor's Note: This column continues our quarterly Turning Points series from the Society for Acupuncture Research (SAR). Author Jiang-Ti Kong, MD, a member of the Board of Directors of SAR, is a pain management specialist, anesthesiologist, and medical acupuncturist at Stanford University School of Medicine. In addition to teaching, research and a conventional pain management practice, Dr. Kong leads the acupuncture service at Stanford Pain Management Center. Her commentary was stimulated by a three pronged strategy on the opioid crisis authored by leaders of the USA National Institutes of Health (NIH) and National Institute on Drug Abuse (NIDA) published in October 2017 in the New England Journal of Medicine. —John Weeks, Editor-in-ChiefAs an anesthesiologist, pain management specialist, and acupuncturist, I have had the privilege of taking care of patients in a variety of settings and also of witnessing the impact of the opioid crisis that is sweeping across the United States. Drawing on expert opinions from multiple disciplines, as well as my personal experiences, I believe that there is great potential for acupuncture researchers and practitioners to contribute significantly to the alleviation of this opioid crisis. Some of these are presently underexplored.Currently, >90 Americans die each day from overdosing opioids and >1,000 a day are treated in the emergency room for opioid abuse. Prescriptions for opioids have quadrupled since 1999 and so have the rates of drug abuse and deaths related to opioids.1 Many factors have contributed to this sharp increase in opioid prescriptions, including the previous assumption in the late 1990s that most pain conditions were medically undertreated, followed by approval of long-acting opioids such as OxyContin in the commercial market.1–3 In addition to the obvious costs associated with lost lives and medical treatments, opioid abuse also leads to profound economic and emotional burdens to the individuals and families affected. It is, therefore, imperative that we come up with timely and effective strategies to ameliorate and eventually halt this crisis.In the October 2017 issue of the New England Journal of Medicine, Dr. Nora Volkow, the director for the U.S. National Institute of Drug Abuse, and Dr. Francis Collins, the director of the U.S. National Institute of Science, outlined three strategies to deal with the opioid epidemic.3 The first strategy involves overdose reversal interventions, thereby reducing the damage caused by circulating opioids. Opioid overdose leads to respiratory suppression, which, if untreated, leads to death. Current standard of care is intravenous or intranasal naloxone, which works by competitively binding to the μ-opioid receptor. Dr. Volkow outlined the development of additional pharmacologic agents and wearable stimulation devices targeting other receptors/nerve structures to protect against respiratory depression. The second strategy involves direct treatments of opioid addiction. Again, outside of the current standard of care (methadone, buprenorphine, and long-acting naltrexone plus psychosocial support), Dr. Volkow presented the development of new formulations and drug targets, as well as vaccines and monoclonal antibodies against some of the most potent opioids. Last but not least, the need to develop and evaluate nonaddictive treatments of chronic pain was emphasized. A variety of treatments were listed, such as new classes of nonopioid medications, various stimulation technologies, and a broader role for precision medicine, which aims to deliver more patient-specific and thus more effective treatment of pain.Although “nonaddictive treatments of chronic pain” is listed as the third objective, it is a key component in the war against the opioid crisis. Multidisciplinary, integrative, and individualized care has long been advocated for the treatment of chronic pain as exemplified by the biopsychosocial model.4 This approach is particularly relevant in the setting of the opioid crisis.5 Recent studies have established that acupuncture is more effective than standard care and placebo in treating multiple chronic pain conditions.6 As such, several guidelines and organizations have already endorsed acupuncture as an important part of the multidisciplinary approach to manage chronic pain.7–9 Therefore, acupuncture can play a significant role in the third strategy in the war against the opioid crisis outlined by the directors of NIDA and NIH.While recognizing the role of acupuncture in managing chronic pain, which has been extensively investigated in the past, I'd like also to bring the reader's attention to other, less explored applications of acupuncture that are also relevant to the war on opioids, in the context beautifully outlined by Drs. Volkow and Collins.First, the transition from acute to chronic pain presents a critical time for interventions. Two great examples of such transitions are the immediate postoperative period10 and the emergency room,1 where acute pain conditions are sometimes hastily treated with potent opioids. Studies have shown that increased consumption of opioids in these settings can lead to long-term opioid dependence.11 Although clinical trials have shown neuroaxial blocks, local anesthetics, and intravenous nonopioid medications can reduce opioid use,10,11 few large randomized, controlled trials have evaluated acupuncture in such acute pain settings, despite the presence of pilot studies demonstrating feasibility and effectiveness of acupuncture in treating acute pain.12–14 More studies are needed to better define the opioid sparing effect of acupuncture in the acute pain setting, and potentially compare acupuncture with established modalities in managing acute pain.Second, perhaps less well known to the general public, is the fact that acupuncture has been used to treat addiction and substance abuse. Electroacupuncture, known to increase the production of endogenous opioids, was shown to reduce the symptoms of opioid withdrawal in both animal and human pilot studies.15,16 Furthermore, auricular acupuncture, delivered by the National Acupuncture Detoxification Association (NADA) protocol, has been used extensively to treat drug abuse disorders.17,18 Despite these existing data, a cursory search of the literature reveals few recent studies of proper design and sample size that address the effectiveness or define the extent of acupuncture in treating opioid addiction. The author is aware of one upcoming study from the State of Maine, where a pilot project was funded to examine the role of NADA as part of the state's response to the opioid crisis.19 More studies are clearly needed to examine the roles of various acupuncture treatments (NADA, electroacupuncture, etc.) in treating opioid addiction.As acupuncture researchers and practitioners, we have the potential to make meaningful contributions to the war against the opioid crisis. Aside from continuing to utilize acupuncture in the treatment of chronic pain, great opportunities exist for us to better define the role of acupuncture in sparing opioids in the treatment of acute and chronic pain, as well as in treating opioid addiction. Finally, emulating Dr. Volkow who called for strong partnership between public and the private sector, we similarly also encourage partnerships between acupuncture practitioners who have access to a great variety of patients and skills, and the conventional medical institutions (i.e., hospitals and medical schools) who have the necessary resources to support high-quality clinical and basic research. As an example, the National Pain Strategy also urged collaboration with integrative healthcare professions.20 Such collaborations between the acupuncture community and conventional medical research entities will potentially yield beneficial results to both advance our science and deliver, better, more integrated care.AcknowledgmentsI wish to thank Dr. Hugh MacPherson for his assistance in developing this commentary, as well as my colleagues from the executive board of the Society for Acupuncture Research for their feedback on the topics discussed in this article.Author Disclosure StatementNo competing financial interests exist.References1 Kolodny A, Courtwright DT, Hwang CS, et al. The prescription opioid and heroin crisis: A public health approach to an epidemic of addiction. Annu Rev Public Health 2015;36:559–574. Crossref, Medline, Google Scholar2 Manchikanti L, Helm S2nd, Fellows B, et al. Opioid epidemic in the United States. Pain Physician 2012;15(3 Suppl):ES9–ES38. Medline, Google Scholar3 Volkow ND, Collins FS. The role of science in addressing the opioid crisis. N Engl J Med 2017;377:391–394. Crossref, Medline, Google Scholar4 Gatchel RJ, Peng YB, Peters ML, et al. The biopsychosocial approach to chronic pain: Scientific advances and future directions. Psychol Bull 2007;133:581–624. Crossref, Medline, Google Scholar5 Stanos SP. Stemming the tide of the pain and opioid crisis: AAPM reaffirms its commitment to multidisciplinary biopsychosocial care and training. Pain Med 2017;18:1005–1006. Crossref, Medline, Google Scholar6 Vickers AJ, Vertosick EA, Lewith G, et al. Acupuncture for chronic pain: Update of an individual patient data meta-analysis. J Pain 2017; pii:S1526-5900(17)30780-0. Google Scholar7 Nahin RL, Boineau R, Khalsa PS, et al. Evidence-based evaluation of complementary health approaches for pain management in the United States. Mayo Clin Proc 91:1292–1306. Google Scholar8 Qaseem A, Wilt TJ, McLean RM, et al. Noninvasive treatments for acute, subacute, and chronic low back pain: A clinical practice guideline from the american college of physicians. Ann Intern Med 2017;166:514–530. Crossref, Medline, Google Scholar9 Weeks J. Early results of a pragmatic trial: Report to a state agency on acupuncture for the underserved amid the opioid crisis. J Altern Complement Med 2017;23:901–902. Link, Google Scholar10 Stone AB, Wick EC, Wu CL, Grant MC. The US opioid crisis: A role for enhanced recovery after surgery. Anesth Analg 2017;125:1803–1805. Crossref, Medline, Google Scholar11 Hah JM, Bateman BT, Ratliff J, et al. Chronic opioid use after surgery: Implications for perioperative management in the face of the opioid epidemic. Anesth Analg 2017;125:1733–1740. Crossref, Medline, Google Scholar12 Barker R, Kober A, Hoerauf K, et al. Out-of-hospital auricular acupressure in elder patients with hip fracture: A randomized double-blinded trial. Acad Emerg Med 2006;13:19–23. Crossref, Medline, Google Scholar13 Dillard JN, Knapp S. Complementary and alternative pain therapy in the emergency department. Emerg Med Clin North Am 2005;23:529–549. Crossref, Medline, Google Scholar14 Goertz CMH, Niemtzow R, Burns SM, et al. Auricular acupuncture in the treatment of acute pain syndromes: A pilot study. Mil Med 2006;171:1010–1014. Crossref, Medline, Google Scholar15 Cui CL, Wu LZ, Luo F. Acupuncture for the treatment of drug addiction. Neurochem Res 2008;33:2013–2022. Crossref, Medline, Google Scholar16 Yu AC, Wan Y, Chui DH, et al. The Neuroscience Research Institute at Peking University: A place for the solution of pain and drug abuse. Cell Mol Neurobiol 2008;28:13–19. Crossref, Medline, Google Scholar17 Janssen PA, Demorest LC, Kelly A, et al. Auricular acupuncture for chemically dependent pregnant women: A randomized controlled trial of the NADA protocol. Subst Abuse Treat Prev Policy 2012;7:48. Crossref, Medline, Google Scholar18 Margolin A, Kleber HD, Avants S, et al. Acupuncture for the treatment of cocaine addiction: A randomized controlled trial. JAMA 2002;287:55–63. Crossref, Medline, Google Scholar19 Weeks J. Maine to begin National Acupuncture Detox Association pilot project. 2017. Online document at: https://www.integrativepractitioner.com/whats-new/all-news/maine-to-begin-national-acupuncture-detox-association-pilot-project/, accessed February 23, 2018. Google Scholar20 Weeks J. Does the New National Pain Strategy Respect Integrative Pain Treatment? 2016; Online document at: https://www.integrativepractitioner.com/whats-new/all-news/does-the-new-national-pain-strategy-respect-integrative-pain-treatment/, accessed February 23, 2018. Google ScholarFiguresReferencesRelatedDetails Volume 24Issue 4Apr 2018 InformationCopyright 2018, Mary Ann Liebert, Inc.To cite this article:Jiang-Ti Kong.Exploring the Multiple Roles of Acupuncture in Alleviating the Opioid Crisis.The Journal of Alternative and Complementary Medicine.Apr 2018.304-306.http://doi.org/10.1089/acm.2018.0083Online Ahead of Print:April 6, 2018Published in Volume: 24 Issue 4: April 1, 2018PDF download