Treatment of Withdrawal Symptoms Associated With Substance Abuse Detox With Acupuncture

CNS depressants are substances that slow normal brain function and are used to treat Anxiety and sleep disorders. Barbiturates such as mephobarbital (Mebaral) and pentobarbital sodium (Nembutal) are used to treat Anxiety, tension, and sleep disorders. Another class of CNS depressants is Benzodiazepines, which includes diazepam (Valium), chlordiazepoxide HCI (Librium), and alprazolam (Xanax). These substances are also used to treat Anxiety and insomnia, as well as acute stress reactions and panic attacks. CNS depressants act to increase the neurotransmitter gamma-aminobutyric acid (GABA), which decreases brain activity and produces a calm and drowsy effect. Used long term, the body develops a tolerance and larger doses are needed to achiever the same effects. In addition, the body becomes physically dependent and experience withdrawal when the drug is stopped or reduced.

Opiates are a group of substances available in street and illicit forms as well as by doctors’ prescription. They act as analgesics by mimicking endorphin-like substances in the brain. Natural opiates are derived from the opium poppy and abuse dates back to the turn of the century (and earlier in the Far East). Naturally occurring opiates include opium, morphine, and codeine. Semi-synthetic opiates include heroine and oxycodine (Percodan). Synthetic opiates are called opioids and include propoxyphene (Darvon), meperidine (Demerol), and methadone. Opiates/Opioids produce a floating sensation, euphoria, decreased respiration, analgesia, drowsiness, and clouded mental function. Tolerance develops rapidly with regular abuse, and this class of drugs is highly addictive.

Western Medicine’s definition of addiction requires two conditions – tolerance and withdrawal. Tolerance involves the adjustments the body makes in the presence of an addictive chemical. More of the chemical is needed to have the same effect. Withdrawal is the physiological response of an organism when the addictive agent is suddenly removed.

Benzodiazepines withdrawal symptoms:
anxiety, panic reactions, insomnia, seizures, and tremors.

Opiate withdrawal symptoms
insomnia, sneezing, violent yawning, weakness, nausea, vomiting, chills, flushing,
ejaculation, abdominal pain, muscle pain.

Treatments for drug addiction vary according to individual needs, however it is not recommended that individuals addicted to benzodiazepines stop using the drug(s) on their own due to potentially life threatening complications associated with withdrawal such as decreased heart rate and seizures. Medically supervised detoxification is advised, as the drug dosage must be gradually tapered off. Behavioral therapy is also recommended. In terms of opiate abuse treatment, either complete abstinence or medication is used for treatment in addition to behavioral therapy. In some treatments methadone is used. It is a synthetic opioid that block the effect of opioids/opiates, eliminating withdrawal symptoms and relieving drug cravings. Methadone has been used for 30 years in the treatment of opiate abuse.

Chinese Medicine and acupuncture have successfully been used to assist in drug detoxification. The use of auricular acupuncture in treating acute drug withdrawal began in Hong Kong in 1972. However, China has a long history of opiate use beginning in the early 18th century. In 1729, Emperor Yung Chen attempted the first suppression of opium when issuing an edict banning the smoking of opium. Opiate use became a major public health concern in the early 20th century China. In 1949, there were thought to be 20 million opiate addicts. I would image that Traditional Chinese Medicine was used to assist in the treatment of addicts during this time.

The mechanism of action of acupuncture in the treatment of Substance Abuse is as follows:
Increases levels of endogenous endorphins
Directly acts on the central nervous system
Increases circulation
Stimulates the immune system

CASE INTRODUCTION

SB is a 33 year-old Caucasian single male who works as an operations director for a DVD distributor in Los Angeles. He found the Yo San University Clinic through a referral from a chemical dependency counselor from the drug detox program at a local medical center where he had sought treatment. He had experienced acupuncture for the first time the day prior at another alternative health care center that was too costly for regular treatments. He alternatively turned to the Yo San University Clinic for treatment.

SB’s first visit at Yo San occurred on September 26, 2003. 15 days prior to this visit, he had entered a drug detox program. He left the center on September 22, 2003, four days prior to his Yo San visit. He entered the drug detox program after 9 months of daily drug use of benzodiazepines (Valium and Xanax) and 1 1/2 months of opiate use. During this 9-month period, crack cocaine (a stimulant) was also used at times for energy to counter the lethargy/sedation from the benzodiazepines.

PRESENTING COMPLAINTS

At his initial consultation, SB complained of physical discomfort associated with drug withdrawal from benzodiazepines and opiates, and less frequent use of crack cocaine. His main areas of concern were:

physical weakness and coordination problems – SB described feeling out of touch with his body and felt like he was walking on wood planks. He described his movements as unsmooth and felt that he couldn’t trust his movements. He also experienced muscle spasms in the arms and legs.

dull stinging physical pain all over body, and especially in chest area. He described feeling physically sensitive.

anxiety, restlessness, and agitation. This was accompanied by insomnia. SB was only able to sleep for 3-4 hours with trouble falling asleep. Palpitations come and go. I addition, he woke up several times during the night to urinate.

The above systems were experienced all the time

In addition to the above chief complaints, SB experienced night sweats. At the time of his visit, he had experienced these for five consecutive nights prior to the visit (since leaving the treatment center). He also experienced heat sensation in the hands, feet, and chest. He sweats easily and frequently felt chilled. While feeling both hot and cold, the feeling of coldness/chills was predominant. SB also experienced dry mouth and thirst, short-term memory loss, and dizziness upon physical exertion. He also experienced diarrhea six times a day with strong odor, low appetite, abdominal distention after eating, and foggy head and memory. He was experiencing no nausea, vomiting or headaches.

HISTORY

SB grew up in Los Angeles. He was in his last drug detox program 10 years ago. Within the last 9 months he misused Valium and Xanax regularly to relieve anxiety, as well as opiates during the month and a half before seeking the substance abuse treatment. His Anxiety stemmed from work and personal relationships. He is in a 5-year relationship. His girlfriend was unaware of his drug usage. She was informed after he left the medical center and was very upset about the news.

CURRENT HEALTH STATUS

SB is a non-smoker. At that time of his visit at the clinic, he was drug free for 15 days. In addition, he was not drinking alcohol. He was also not drinking coffee, tea, or any caffeinated beverages.

SB has history of exercising regularly - working out at the gym 3 times per week. This lessened during his substance abuse recovery time.

He is not taking any medications. One day prior to his Yo San University visit, he had received Chinese herbs at another healing institute.

There is not known allergy to medications.

REVIEW OF ZANG-FU SYSTEMS

SB’s symptoms of night sweats, thirst, dry mouth, insomnia, five heart heat, and frequent urination suggest Kidney involvement. His presentation of diarrhea, poor appetite, foggy head, and muscle weakness points toward Spleen weakness. His Anxiety, insomnia, restlessness, and palpitations suggest Heart involvement as well. The dizziness and muscle spasms suggest Liver involvement.

THREE DIAGNOSTIC SIGNS

SB presented with a pale complexion and anxious demeanor. He appeared unsettled and overwhelmed by the busy, loud atmosphere in the lobby of the clinic. He seemed relieved when able to come back to the treatment room. His gait toward the room was stiff and deliberate. As he sat in the room during the intake, he appeared fidgety and uncomfortable in his body. The Anxiety could also be seen in his eyes.

On examination, his tongue appeared purple-red with a red tip with a scanty yellow coat. It showed teeth marks and quivered.

His pulse was deep, thready, rapid and wiry on both the right and left sides. The left chi position was also weak.

ASSESSMENT AND IMPRESSION

SB’s TCM diagnosis: Liver and Kidney yin deficiency with heat, Spleen qi deficiency, and Liver qi stagnation.

The predominance of Liver and Kidney yin deficiency with heat is demonstrated through the night sweats, 5 heart heat, insomnia, dry mouth, thirst, and muscle spasms (due Liver yin deficiency not nourishing the sinews/muscles). This Kidney yin xu has also affected the Heart yin, and its deficiency has manifested not only in insomnia, but also with palpitations and Anxiety. His thready, rapid and deep pulse further demonstrate yin deficiency with heat, His red-purple tongue with a scanty yellow coat also indicates deficiency of yin.

Spleen qi deficiency can be seen through his poor appetite, diarrhea, abdominal distention, foggy head, and weakness of the body. In addition, his tongue shows teeth marks and quivers.

Liver qi stagnation is seen in his agitation. His pulse also has a wiry quality and there is a purple hue to his tongue.

TREATMENT PRINCIPLE, OBJECTIVE, AND PLAN

Treatment principle: Tonify Liver and Kidney yin, tonify Spleen qi, move Liver qi, and calm Shen.

Treatment plan: Daily acupuncture treatments for 2 weeks (with the exception of Sundays because the Yo San Clinic is closed). After the initial two weeks, acupuncture treatments three days/week for 2 weeks. Treatments were then reduced to twice a week for 2-3 weeks and after that period to once a week for two month.

Daily use of Chinese patent medicines was recommended.

Point usage: Traditional acupuncture points were used predominately with some usage of auricular acupuncture.

Initial Treatment
Liver 3 – Nourishes Liver blood and Liver yin, and spreads Liver qi. It used to treat insomnia, thirst, and dizziness

Kid 3 – Nourishes Kid yin and clears deficiency heat. As the shu stream and yuan source point, it is a key point in treating kidney zang disharmony.

St 36 - Fortifies the Spleen and fosters original qi, tonifies qi and nourishes blood and yin, clears fire and calms the spirit, activates the channel and alleviates pain. Treats poor appetite, diarrhea.

Sp 6 - Tonifies the Spleen and Stomach, harmonizes the Liver, tonifies the Kidneys, and regulates urination, Calms spirit, and activates the channel and alleviates pain. Treats the feeling of heaviness in the body, diarrhea, and heat in the soles of the feet,

Pc 6 - Unbinds the chest and regulates qi, regulates the Heart and calms the spirit, harmonizes the Stomach, and clears heat. Treats insomnia, distention in the abdomen, poor memory, and Anxiety.

Ren 4 - Tonifies and nourishes the Kidneys, warms and fortifies the Spleen, fortifies the original qi. Treats lack of strength in the four limbs, heaviness in the body, and tremors.

Ren 6 – fosters original qi, tonifies the kidneys, regulates qi.

Ren 17 – Regulates qi and unbinds the chest,

Yin Tang – Calms Shen.

Si Shen Cong – Calms Shen. Treats insomnia and poor memory.

Du 20 – Calms the spirit and benefits the brain. Treats agitation, and sensation of heat in the heart, poor memory, and lack of mental vigor.

Ear Shen Men – Calm the spirit. Alleviates stress, Anxiety, insomnia, restlessness, and excessive sensitivity.

(Needles used were 36 gauge – thin needles were used due high sensitivity of the body from drug usage and detox).

After the treatment, SB reported feeling better and that walking/physical movement felt more comfortable and smooth than prior to the treatment.

Chinese patent medicine: We recommended he continued with the patent formula given by the another Chinese medicine practitioner the day prior until the patents were completely used.

Shuo Xiao Zao Ren An Shen Wan – to calm shen and nourish yin, help sleep
Zhen He Lin Pill – assists in detoxification

Additional points used on subsequent visits:

An Mian – Calms the spirit and pacifies the Liver. For insomnia, palpitations, agitation and restlessness.

Heart 7- Calms the Spirit and tonifies the Heart. Treats insomnia, poor memory, palpitations, heat in the palms, and cold shivering.

Gb 34 – Benefits the sinews and joints, spreads Liver qi. Treats contraction of the sinews.

Kid 2 – Clears deficiency heat, regulates the Kidneys. Treats night sweats,

Ear Point Zero – balances whole body energy, regulates internal organ dysfunction. This point acts on the nervous system.

PREVENTION AND LIFESTYLE MODIFICATIONS

SB has made many lifestyle adjustments since seeking treatment for his substance abuse. He regularly attends 12 step program meetings, on a daily basis at the beginning of his treatment. He is also in regular contact with his 12-step program sponsor. In addition, he shared that he has made the choice to no longer be in contact with certain friends he abused drugs with. His drug detox program arranged to have supportive assistance as he cleaned up his apartment and helped him remove all the abused substances before coming home.

PROGRESS AND PROGNOSIS

SB has made good progress since his first visit in late September.

After his first visit he shared that he felt better in his physical movements and he appeared more comfortably and relaxed after the treatment. By the fourth visit he felt that his strength and appetite were beginning to come back. He shared that he was feeling more confident in his physical movements. His bowel movements were also more regular. By his fifth and sixth visit, his mental acuity was coming back. He was sleeping approximately 6 hours a night but continued to have night sweats. He also continued to have Anxiety and emotional ups and downs.

By October 3, 2003, he felt that his temperature fluctuations had mellowed and his Anxiety level had improved. He was still having trouble falling asleep (1 hour) and continued with night sweats. By his next visit on October 8th, he reported that the night sweats had lessened and that he felt strong enough to go back to the gym. He continued to have foggy head and poor memory. His other digestive complaints such as abdominal distention have also diminished, and he reports that his appetite for food is "too good.” His pulse began to show a slippery quality, and continue to be wiry and rapid.

With his physical coordination and movement was improved, his main concerns were his Anxiety and insomnia. By November 6th, he was able to fall asleep easily and was able to sleep through the night for five days after his last treatment on October 30th. He also shared feeling some depression since things in his life had calmed down. He continued to have relationship issues with his girlfriend and they are seeking couples counseling. During this time his formula was changed to the patent medicines Chai hu jia long gu mu li pian to treat his emotions and soothe the liver and Gan mai da zao pian to support the Heart and Spleen qi.

His difficulty with sleep (falling asleep and staying asleep) continued through January, however, it was improved with some nights being able to sleep 7 hours. He reported in January that he has cravings come up several times a week but that there have been "no close calls.” He talks to his groups about this issue or calls his sponsor. He energy is better and his sleep is overall improved. During this time his tongue began to present with deviation to the left side and a foamy white coat on the sides. In January, SB’s formula was changed to Wen Dan Tang to address both the phlegm/dampness (seen on the tongue) as well as his anxiety. In addition, he remained on Gan mai da zao pian to continue nourishing the Heart and Spleen.

His most recent visit was March 4, 2004. He was 174 days sober, close to 6 months. He continues to go to group meetings. He reports that he sleeps 7 hours a night and rarely wakes up during the night. He continues to have some difficulty falling asleep (1/2 hour). His pulses are much changed since his first visit. The left side is thready and slippery. The right side is wiry and slippery. His tongue is dusky-red and quivers. He continues to have some anxiety.

DISCUSSION

In this case, we used traditional acupuncture to treat symptoms related to drug detox. The points chosen addressed the underlying condition presented by the patient. Another alternative substance abuse treatment protocol includes only auricular acupuncture as developed by the National Acupuncture Detoxification Association (NADA). The protocol involves needling the following ear points - sympathetic, shen men, kidney, liver, and lung. The needles are inserted in the order of the above sequence. The same treatment is given regardless of the type of drug abused and is given daily.

While drug detoxification can be a challenging emotional and physical experience for the patient, Traditional Chinese Medicine can be a successful adjunct therapy to a drug detox program and counseling. The use of acupuncture and herbal medicine can address both the physical and emotional symptom and provide a support for the body and spirit.

REFERENCES:

Brumbaugh, Alex. Transformation and Recovery: A Guide for the Design and Development of Acupuncture-Based Chemical Dependency Treatment Programs. Santa Barbara: StillPoint Press, 1994.

Given L.Ac., Steve. Lecture Notes for Acupuncture and Substance Abuse. 1999.

www.nida.nih.gov - National Institute of Drug Abuse

SAMSA, agency of Department of Health and Human Services. (website)

Cohen, Howard M., Law-Yone, Byron, and Lu, Sunan. ”Poppy to Fugu: a Historical Perspective of the Treatment of Opiate Addiction in China.” Journal of Chinese Medicine. Number 60. May 1999.

Deadman, Peter, and Al-Khafaji, Mazin. A Manual of Acupuncture. East Sussex: Journal of Chinese Medicine Publications, 1998.