Journal of Substance Abuse Tre

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 Parkinson’s 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 &

O’Neil, 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 (D’Alberto, 2004). But is this treatment effec-

tive? The purpose of this article is to draw conclusions,

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.

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 Emperor’s Classic of Medicine,Qthe oldest known book about Chinese medicine and one of

the earliest known medical texts (also known as bPlainQuestions 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

atment 30 (2006) 309–314

J.B. Jordan / Journal of Substance Abuse Treatment 30 (2006) 309–314310

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 balance—usually an excess of yin or yang

energies—as all meridian points are associated with yin

and yang. Usually, a three-level pulse diagnosis on the

wrist related to the body’s 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 College’s 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 bacupunctureQin 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 Parkinson’s 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 (D’Alberto, 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

(1–45%) from treatments, tiredness (2–41%), and bleeding

(0.03–38%). Fainting and syncope were uncommon, with

an incidence of 0–0.3%. 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) 309–314 311

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 practitioner’s 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 bcuresQenthusiastically 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

(D’Alberto, 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 weredetoxified 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) 309–314312

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 pre–post 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 D’Alberto (2004) could not confirm acupuncture to be an

effective treatment for cocaine abuse (alone). D’Alberto

reviewed several databases to answer the question: bIsacupuncture effective in the treatment of cocaine addiction?QD’Alberto 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) 309–314 313

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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