ACUPUNCTURE, MEDICATION and VITAMINS In the TREATMENT of ADDICTION
By Robert A. Nash, M.D., F.A.A.N., L.P.Ac.

I have been actively involved in understanding addiction for at least the past 15 years and have found that traditional approaches meet with less than satisfactory results. This has prompted me to pursue other avenues of investigation, including completion of the UCLA Acupuncture Course for Physicians. I have been a Licensed Physician Acupuncturist since 1992. I have lectured at several venues, including the State of Maryland Alcohol and Drug Abuse Administration; 1 the 5th and 6th International Conferences on Drug Policy Reform in Washington, D.C.; and the Baltimore Substance Abuse Systems.2 I spoke for the medicalization of addiction and was quoted in the National Report on Substance Abuse.3 My paper, "Use of Energy Medicine in Drug Treatment," was published in New Frontiers in Drug Policy in 1992.4

My 25 years of clinical research with my own patients in the field of chronic pain, my long term interest in practical neurochemistry and my expanding treatment modalities including acupuncture prompted me to write "The Serotonin Connection." 5 In "The Serotonin Connection" I address addiction as a disordered neurochemical state of low serotonin and endorphins which is genetically determined in most patients. This became a major interest area of mine after the presentation at the National Science Foundation Symposium in 1988 of a paper that showed an altered metabolism of cyclic-AMP in genetically produced alcoholic rats. I began inquiring into the sleep patterns and use of alcohol, barbiturates, benzodiazepines and narcotics in my pain patients. It soon emerged that even though sleep patterns could be reestablished with serotonergic medications, the chronicity of the pain persisted. I then began to slowly removed the above four categories of drugs from the chronic pain patients after my research indicated that alcohol, barbiturates and benzodiazepines react at the neuronal cell level at the gamma amino butyric acid (GABA) gate. Within 4 to 8 weeks the majority of the chronic pain patients experienced a marked reduction in pain with many becoming pain free. I recalled that this was often seen in alcoholic patients withdrawing in hospital and the endorphins came to mind. I hypothesized that alcohol, barbiturates, benzodiazepines and narcotics act in unknown ways at the GABA gate to inhibit the production of endorphins which is maximized at deep state IV or delta sleep.

This was based on multiple studies by H. Moldofsky and others that showed an alpha (brain frequencies of 8-12 hertz) delta (brain frequencies of 0-4 hertz) sleep disturbance 6-10 in approximately 80 percent of chronic pain patients. Once the patients came slowly off all habituating medications including alcohol an amazing decrease in their pain occurred. As I learned more about acupuncture and the scientific basis for same, the same two neurochemicals reemerged, serotonin and endorphins. I hypothesized that the deep muscle relaxation and maximal production of endorphins that occur at deep stage IV or delta sleep is markedly disturbed by the ingestion of alcohol, barbiturates, benzodiazepines and narcotics. The GABA gate of the neuron appears to be involved.

I then asked these patients more detailed histories including family history of addiction or other obsessive compulsive behaviors. I recalled the Science article insert in May 1986 issue that stated Freudian psychotherapy did not work and that neurochemical changes worked. I later asked Dr.Candice Pert which came first the neuropeptide or the emotion? She answered as most neuroscientists would that the neuropeptides preceeded the emotions.

By integrating the above with two decades plus of clinical experience I developed a 13 question test that each of my patients is given. It is published in "The Serotonin Connection," is copyrighted in 1995 and is reproduced here for educational purposes.

NASH SEROTONERGIC INDEX c. 1995

YES NO
1. Do you usually skip breakfast? ____ ____
2. Are you refreshed upon awakening from sleep in the morning? ____ ____
3. Do you have outbursts of anger for no apparent reasons? ____ ____
4. Were your parents or grandparents heavy or daily users of alcohol or cigarettes? ____ ____
5. Do you have difficulty sleeping? ____ ____
6. Are you or your parents workaholics? ____ ____
7. Do you prefer to be in control of most situations? ____ ____
8. Do you have morning stiffness if you don't sleep under more than one blanket at night? ____ ____
9. Does noise bother you? ____ ____
10. Do you feel really good about doing well in school, sports or your job? ____ ____
11. Do you eat before going to bed? ____ ____
12. Do you bite your fingernails? ____ ____
13. Are you a long distance runner or exercise enthusiast? ____ ____

I devised the Index to quickly determine if serotonin (S) or norepinephrine (NE) was deficient. I viewed these two neurochemicals as being on opposite ends of a see-saw. When one is balanced and feeling well and is in good health the yes and no answers are fairly balanced. When someone is deficient in NE they may answer only 1 to 3 questions yes and the remainder no. These tend to be true panic attack patients with true low NE and high anxiety states to match. These patients should receive norepinephrine, medications and never serotonergic medications, which might exaccerbate the imbalance. The opposite is often seen in very low serotonin patients, often obsessive compulsive disorder(OCD), addictive, chronic pain, sleep disturbed and poor impulse control patients. They may answer 1 to 4 questions no and the rest yes. Since vigorous exercise increases both serotonin and endorphins, if the patient answers question 13 yes, They maybe considered low serotonin patients regardless of the number of yes answers. If they answer question 12 yes they likewise may be considered low serotonin patients.

How can this knowledge be put to use in the treatment of addicted patients? Addiction is complicated by a low endorphin state. The role of endorphins in opiate addiction has been known since the 1970's and is reviewed in the Psychiatric Clinics of North America, Sept. 1983.11 Acupuncture has been elegantly shown to markedly increase endorphins and serotonin in a matter of minutes.12 Others have combined auricular acupuncture plus medication13 with very positive results. Still others are more cautious and question the effectiveness in drug abuse treatment.14 15

Addiction has become an increasing national criminal justice, economic, family and social problem. This has prompted policy articles calling for balance in the treatment and interdiction of drugs. Acupuncture has now become increasingly known to the public via print and visual media.16,17,18 Even legal and legislative aspects of alternative health care in the United States has been and currently is being addressed.19 The U.S. has the highest per capita incarcerated population in history. It is now at least 1.3 million with approximately 55 percent being black Americans.20 An additional 4 million are on parole. Recent estimates are that 75 percent of these were on an addictive substance or were seeking to obtain money to obtain an addictive substance when apprehended. This is a significant number of our population. If low serotonin and low endorphins are genetically predisposed, as I hypothesize, then much of our criminal and societal problems may have a pathological correctable basis. Succinctly addiction and much criminal behavior maybe secondary to genetically induced low serotonin and secondary low endorphins due to a sleep disturbance.

Michael O. Smith,M.D., D.Ac. has shown over time how effective acupuncture is in treating the New York City addict population. His pioneering work at Lincoln Hospital in New York City has brought him national and international recognition. He founded the National Acupuncture Detoxification Association, Inc. (NADA) and has provided information and teaching to numerous cities. In New York City alone, working with the criminal justice system, better health to addicts, their children and a marked total cost savings to the city as a whole has been effected.21 Smith has developed the most comprehensive program to date. Beginning in 198822 and continuing with his successes to the present, he reported at a NADA conference in 199323 that acupuncture was the foundation for psycho-social recovery. He presented testimony to the National Institutes of Health, Office of Alternative Medicine, in May 1993.24 He outlined his Lincoln Hospital Acupuncture Drug Abuse Program and urged a greater national acceptance of acupuncture in detoxification of drug addiction.

When U.S. Attorney General, Janet Reno, was prosecutor for Dade County, Florida, she instituted a first time drug offender program. First time offenders could opt for acupuncture, eight months of aftercare to include counseling, school or employment. This program has continued and expanded. Those who chose the acupuncture pathway had only a 15 percent recidivism rate with either the abused substance or the criminal justice system. Those who chose 1 year of incarceration had almost an 85 percent recidivism rate with both the abused substance and the criminal justice system. The estimated costs today are approximately $1,500 for the acupuncture pathway and $22,000 for the incarceration pathway. Although Attorney General Reno was a pioneer in the use of acupuncture for chemical detoxication25 the anticipated use of acupuncture or the focusing on the medical model of addiction with treatment of low serotonin states and subsequent low endorphins has not progressed as rapidly as hoped for.

Acupuncture has been shown to be very helpful in chronic alcoholism26, as well as being 90 percent successful in nicotine detoxification.27 Alcohol, nicotine, food and drug addictions have all been reported to respond to acupuncture. I have had similar success rates as a physician acupuncturist over the past seven years. However, I use acupuncture as part of an integrated program that also addresses a presumed genetic low serotonin state and a presumed micronutrient deficiency state. It has been my experience that serotonergic medications must be continued for very lengthy periods, i.e.years, for the detoxification efforts to be most rewarding. I have also found that long term nutritional supplementation for micronutrient balance is also needed.

I will use two illustrative cases, both dealing with crack cocaine, to show the importance of not only acupuncture, but also the continuing need for serotonergic medications and micronutrient support.

CASE REPORTS:

CASE # 1
This is a 54 year old right handed white female who had been using crack cocaine on a daily basis from 1991 until shortly before she presented to me in very early November 1998. She was finally hospitalized by her family in mid September 1998 and underwent the standard detoxification and 12 step program . She related the stress was on her weakness as an individual. Little if any education about nutrition or neurochemical balance was remembered by the patient. She had a very supportive husband and daughter who accompanied the patient to the office and have continued to support her throughout her treatment. After her 4 to 5 weeks of hospitalization at a cost of $43,000, she was drug free less than 24 hours after discharge. Her family made an appointment with me and the patient abstained from the crack cocaine for 3 days before her office visit on a Monday. We immediately implemented our integrative program. This consists of Prozac 10 or 20 mg q AM with trazodone 50mg q hs for 4 days then 100 mg q hs. These medications are adjusted upward on a weekly basis as warranted. A good multivitamin and mineral supplement in megadoses is recommended as well as highdose vitamin C, 1000 mg qid. Acupuncture is performed daily for five consecutive days (Monday through Friday) during the first week. It then is decreased to three times during the second week (Monday, Wednesday, Friday). It is further decreased to twice a week during week 3 (Monday and Thursday) and once on Monday during week four. The acupuncture during weeks 3 and 4 is for Adlerian support as well as for the serotonergic and endorphinergic boost.

This patient remained completely drug free until March 1999. She had two lapses in March , each of one day's duration. She felt so good that she decreased and stopped the serotonergic medications without my knowledge. This was a learning experience for the patient and it was agreed to that no further medications would be altered without my recommendation. She remained drug free until late August 1999. She saw her dentist who saw a "possible' abnormality in her mouth "which could be cancer". She was referred to an oral surgeon. Little did the dentist know that the patient's adoptive mother had died of mouth cancer. Fearing the worst and forgetting there was no blood relationship to her adoptive mother the patient lapsed for 2 consecutive days. Once the oral surgeon gave her a clean bill of health and with another week of acupuncture she has remained drug free since early September,1999. In summary the patient has used crack cocaine for a total of 4 days in a calendar year at an approximate cost of $1,000 total. It is expected that she will remain drug free as she has learned that her family and I are available when she is fearful. Acupuncture will be used instead of the substance should she feel like she will use again. It's almost as cheap and is more user friendly.

CASE # 2
This is a 39 year old left handed white male who has been almost a daily user of crack cocaine since 1993. He has a poor support system. He was divorced and has a 12 year old son being raised by his very assertive and dominant mother. He has no medical insurance and worked only enough to cover his habit and minimal expenses. His diet was fast foods with no micronutrient supplementation. He presented as a new patient with the mother agreeing to pay for my initial visit and initial course of acupuncture in mid November, 1998, approximately 2 weeks after the above patient presented. His longest time off the substance had been four months, with severe daily craving. He followed the same protocols as the patient in case #1. He remained drug free through February 1999 with no craving. He also stopped his serotonergic medications due to lack of funds to buy his medication and in part because he felt so well. He also stopped his vitamins for the same reasons. He began to use again and presented in March1999. Medication and supplementation were started and a short course of acupuncture was given, (3 days). He remained drug free until late June 1999, when he again used his substance. He had financial problems, his son was acting out at his mother's house and his mother was making strong suggestions to the patient. An almost love - hate relationship appeared at times, so the strong family support system was not present as it was in case #1.

We saw the patient in late June or early July 1999. Again we stressed the need for medication and supplemention and did two successive days of acupuncture. He has an appointment scheduled in early November 1999 and just has to call to get acupuncture instead of using. His prognosis is more guarded than case#1. He has realized he can go without craving when he is detoxified and takes his serotonergic medications and micronutrient supplementation.

ACUPUNCTURE PROTOCOL:
All of the acupuncture treatments are the same. Because of the success I have had with nicotine detoxification using the auricular and the American - French systems together, I vary only one or two auricular points depending on the substance. The auricular points I use for crack cocaine detoxification are the sympathetic, point zero, master sensory point, Lung 1, Lung 2, Kidney 2 and Liver 1 {optional). I also use Gall Bladder 8 and 18 with Spleen 3. Electrical stimulation for 45 minutes is used with low frequency with the negative lead to Spleen 3 and the positive lead to Gall Bladder 18. I also use GV 20 si seng cong with Liver 3 and Large Intestine 4 to maximally boost the endorphins, serotonin and valium like anxiolytics.

DISCUSSION:
Only a portion of my practice is acupuncture and detoxification I was singularly impressed by the cost differential and outcomes of these two relatively recent patients. I do not have any counseling available at my office and since these patients have been exposed to the traditional 12 step programs they did not desire any more counseling for the present. My approach stresses the genetic predisposition to addiction due to low serotonin and possible inadequate micronutrition. This places no blame, no weakness and only an inherited problem that can be dealt with. Most patients know this intuitively and once they realize I wish to help their genetically induced neurochemical imbalance, most are relieved and very cooperative. Once restorative sleep is reestablished with the serotonergic medication, and boosted by the acupuncture, most patients do very well. The need for micronutrient supplementation is felt to be very important.

CONCLUSIONS:
My experience has demonstrated to me that in a complex process such as addiction an integrated approach is the best, Acupuncture is a nonverbal treatment boosting serotonin and endorphins. This along with the micronutrients and serotonergic medications bring rapid neurochemical balance, restorative sleep, and minimal to no cravings. The medications and supplementation must be continued for years or possibly even a lifetime. There is increasing evidence that all addiction may have low serotonin as a common denominator. This is easily treated medically and reenforces the cost effectiveness and known mechanisms of acupuncture in the treatment of all addictions, including nicotine addiction. .

1 Nash, Robert A.., Energy Medicine, Alternative Strategies: An Adjunct to Traditional Treatment, State of Maryland, Alcohol and Drug Abuse Administration, Ocean City, Maryland, Oct., 29-30, 1990.

2 Nash, Robert A., Innovations in Addictions Treatment Conference, Baltimore Substance Abuse Systems, St. Michaels, Maryland, Oct., 1-2,1992.

3 Medicalization of Drug Addiction: Sinister, Misleading or Hopeful? The National Report on Substance Abuse, Buraff Pub., Washington, D.C., Vol. 7, No. 1, pp. 4-5.

4 Nash, Robert A., Use of Energy Medicine in Drug Treatment, New Frontiers in Drug Policy, The Drug Policy Foundation, Washington, D.C., ISBN 1-89-9189-04-6, pp. 250-255.

5 Nash, Robert A., The Serotonin Connection, Journal of Orthomolecular Medicine, 1996, Vol. II, No. 1, pp. 35-44.

6 Fricton, J.R. and Awad, E.A.: Myofascial Pain and Fibromyalgia. Advances in Pain Research and Therapy,. New York. Raven Press. 1990;17.

7 Moldofsky, H.: Sleep-Wake Mechanisms in Fibrositis. J. of Rheumatology, 1989; 16 Suppl. 19: pp. 47-48.

8 Moldofsky, H.: Pain and Sleep, presented at Sleep Disorders Conf., Phoenix, AZ, 1992.

9 Moldofsky, H.,Lullis, C., Lue, F.; Sleep Related Myoclonus in Rheumatic Pain Modulation Disorder (Fibrositis Syndrome), J. of Rheumatology, 1986; Vol. 13: pp. 614-617.

10 Moldofsky, H., Saskin, P., Lue, F.: Sleep and Symptoms in Fibrositis Syndrome After a Febrile Illness, J. of Rheumatology, 1988; Vol. 15: pp.1701-1704.

11 Gold.M., Rea, W., The Role of Endorphins in Opiate Withdrawal and Recovery, Psy. Clin. Of North America, Sept. 1983; Vol. 6: pp.489-520.

12 Pomeranz, B. Recent Advances in Acupuncture Research, Temple Univ. Center for Frontier Sciences Symposium, Apr 26, 1994, tape.

13 Kroening, R. Oleson, T., Rapid Narcotic Detoxification in Chronic Pain Patients Treated with Auricular Acupuncture and Nalozone, Int'l J. of Addictions; Vol. 29; pp.1347-1358.

14 Swan, N., Experts Divided on Effectiveness of Acupuncture as a Drug Abuse Treatment, Treatment Issues, Nat'l Inst. of Drug Addiction, Sept./Oct. 1992, pp.8-12. ;

15 Goldstein, A., Lalant, H. Drug Policy: Striking the Right Balance, Science, Sept.28, 1990; Vol. 249: pp. 1513-1521..

16 Conquer the Pain and More with Acupuncture, Prevention, Dec. 1994, pp.76-79.

17 Weiss, R., Medicine's Latest Miracle, Health, Jan./Feb. 1996, pp.70-78.

18 Acupuncture, Consumer Reports, Jan., 1994, pp.54-59.

19 Sale, D.M., Overview of Legislative Developments Concerning Alternative Health Care in the United States, The Fetzer Institute, Kalamazoo, MI., 1995, Acupuncture, pp. 1-6.

20 The Drug War in Black and White, The Drug Policy Letter, No. 28, winter, 1996.

21 National Acupuncture Detoxification Association, Inc. (NADA) papers, #1013 (1988), newsletter, (Nov. 1990), #1011 (1991), #2002 (1991), #2004 (1992), #2003 (1993).

22 Smith, M.O., Khan, I., An Acupuncture Programme for the Treatment of Drug -Addicted Persons, Bulletin on Narcotics, Vol. XL, No. 1: pp.12-18.

23 Smith, M.O., Acupuncture Helps Programs More than Patients, NADA Conference, 1993, pp.1-9 .

24 Smith, M.O., Lincoln Hospital Acupuncture Drug Abuse Progam, Testimony presented to NIH-OAM, May 21, 1993.

25 Acupuncture in Recovery, Guideposts, Charter Issue, May, 1993.

26 Bullock, M. et. Al., Controlled Trial of Acupuncture for Severe Recidivist Alcoholism, The Lancet, Jun. 1989, Vol. 234: pp. 1435-1439.

27 Biomedical Research on Acupuncture, An Agenda for the 1990's, Conference Summary, American Foundation of Medical Acupuncture, Jun. 14, 1993, pp.67-69.