ACUPUNCTURE AND

OPIOIDSJason Go, R.Ac, Dipl. Ac. (NCCAOM), MSAOM

Blue Dragon Acupuncture

jgoacupuncture@gmail.com

JASON GO

Owner/Acupuncturist at Blue Dragon Acupuncture

1201 Stone Street

Suite 2 (Michigan Rheumatology Office)

312-622-3659

jgoacupuncture@gmail.com

Facebook page: Blue Dragon Acupuncture Clinic

MSAOM and BS in Nutrition from Midwest College Of Oriental Medicine, Chicago

BS in Biopsychology and Cognitive Science from University of Michigan, Ann Arbor

PRESENTATION OUTLINE

What is Acupuncture?

Acupuncture Pain

Mechanisms of Action

Acupuncture and Opioid Use

Acupuncture is Safe

Acupuncture is Cost Effective

WHAT IS TRADITIONAL CHINESE

MEDICINE (TCM)?

4 major principles:

1. Your body is an integrated whole

2. You are completely connected to nature

3. You were born with a natural self-healing ability

4. Prevention is the best cure

ACUPUNCTURE

“Acus”= Needle in Latin

Def’n: “The insertion of extremely thin

needles through the skin at strategic

points in the body.” – Mayo Clinic

ACUPUNCTURE AND

OPIOIDSHow can acupuncture impact the opioid

epidemic?

ACUPUNCTURE AND PAIN

ACUPUNCTURE BEING RECOMMENDED AS

FIRST-LINE NON-PHARMACOLOGICAL

THERAPY

FDA- May 2017-”Blueprint for Prescriber Education for Extended-Release and Long-Acting Opioids”

Doctors become informed about non-pharmocological options

National Academies of Sciences, Engineering and Medicine

Report to outline state of science regarding prescription opioid abuse and misuse

Recommends more public education, reimbursement models and support for non-drug approaches

Effective Jan1, 2018: Joint Commmision

Mandated hospitals provide non-pharmacological pain treatment modalities

ACUPUNCTURE IN THE ER

Acupuncture in Emergency rooms

St Francis Regional Medical Center and Abbott Northwestern

Study of acupuncture vs morphine: 300 patients (150 in each

group)

Acupuncture: more effective, faster and better tolerated

Success rate: 92% in acu vs 78% in morphine

Resolution time: 16+/- 8 minutes vs 28 +/- 14 minutes

Adverse effects: overall 89, 85 in morphine, 4 in acu

ACUPUNCTURE AND PAIN

STUDIES

ACUTE PAIN

Xiang, A., Cheng, K., Xu, P., Liu, S.

Systematic Review of 13 trials

Acupuncture was more effective than sham acupuncture and

injection of pain killers

CHRONIC PAIN

2007: Weidenhammer W., Strong, A., Linde, K., Hoppe, A.,

Melchart, D.

454,920 patients- Headache, low back pain or osteoarthritis

Acupuncture had marked or moderate effectiveness

76% of cases

8727 physicians

CHRONIC PAIN (CONT)

2016: American Specialty Health Incorporated Health Services

Department

2 year retroactive study

Over 89,000 patients

93%- acupuncturist was successful in treating musculoskeletal

pain

CHRONIC PAIN (CONT)

2012: Vickers, AJ, Cronin, AM, Maschino, AC, Lewith, G, MacPherson, H, Foster, NE, et.al.

Meta-analysis of 17,922 patients

“Acupuncture is effective for treatment of chronic pain and is therefore a reasonable referral option. Significant differences between true and sham acupuncture indicate that acupuncture is more than a placebo.”

2016: MacPherson, H, Verstocke, EA, Foster, NE, Lewith, G, Linde, K and Sherman, KJ

Follow up: benefits persisted 12 months after end of treatment

EFFECTIVENESS AND EFFICACY OF

ACUPUNCTURE

According to Fan, et. Al. (2017)…Strongest evidence for

1. Back pain

2. Neck pain

3. Shoulder pain

4. Chronic headache

5. Osteoarthritis

EFFECTIVENESS AND EFFICACY (CONT)

ACUPUNCTURE EVIDENCE PROJECT (MAR

13-SEP16)

Evidence of positive effect:

Allergic rhinitis (perennial and seasonal)

Chemotherapy induced N/V

Chronic LBP

HA (tension and chronic)

Knee osteoarthritis

Migraine prophylaxis

Post-op N/V

Post-op pain

EFFECTIVENESS AND EFFICACY (CONT)

ACUPUNCTURE EVIDENCE PROJECT (MAR

13-SEP16)

Evidence of potential positive effect:

Acute LBP

Acute stroke

Ambulatory anesthesia

Anxiety

Aromatase inhibitor induced arthralgia

Ashtma

Back/Pelvic pain during pregnancy

Cancer pain

Cancer related fatigue

Constipation

Craniotomy anesthesia

Depression

Dry eye

Hypertension

Insomnia

IBS

Labor pain

EFFECTIVENESS AND EFFICACY (CONT)

ACUPUNCTURE EVIDENCE PROJECT (MAR

13-SEP16)

Evidence for potential positive effect (cont)

Lateral elbow pain

Menopausal hot flashes

Modulating sensory perception thresholds

Neck pain

Obesity

Peri- and post-menopausal

insomnia

Plantar heel pain

Post-stroke insomnia

Post-stroke shoulder pain

Post-stroke spasticity

PTSD

Prostatitis pain and pelvic pain syndrome

EFFECTIVENESS AND EFFICACY (CONT)

ACUPUNCTURE EVIDENCE PROJECT (MAR

13-SEP16)

Evidence of potential positive

effect (cont)

Post colorectal cancer

resection

Restless leg syndrome

Schizophrenia

Sciatica

Shoulder impingement

syndrome

Shoulder pain

Smoking cessation

Stroke rehab

TMJ

EFFECTIVENESS/EFFICACY (CONT)

Statistics based on systemic reviews and meta-analysis

1. Knee osteoarthritis

2. Sciatica

3. Lateral elbow pain

4. Plantar heel pain

5. Post surgical pain

OSTEOARTHRITIS OF KNEE

2013: Corbett, MS, Rice, SJC, Madurasinghe V, et.al.

Meta analysis comparing physical treatments

Acupuncture had the largest effect

Over exercise, sham acupuncture, weight loss

TOTAL KNEE ARTHROPLASTY

2018: Chen D, Sheng, D, Xu, JL, Zhang, YY, Lin TY

Electroaccupunture

Visual analogue scale (VAS) significantly lower in EA

No significant differences in ROM

Frequency of pushing drugs (morphine, ropivacaine, droperidol

and sodium chloride) was lower in EA group (5% vs 15%)

“Electroacupuncture combined with pain relieving drugs into an

integrated treatment protocol is more effective than pain-

relieving drugs as a monotherapy.”

SHOULDER IMPINGEMENT SYNDROME

2015: Dong, W., Goost, H., Lin X-B, et.al.

Compared treatments in addition to exercise

Acupuncture was most effective out of 17 treatments

Outperformed- steroid injections, NSAIDs, and ultrasound

SCIATICA

2016: Lewis, R

Examined 20 treatments for sciatica

Acupuncture was 2nd most effective

After biological agents

Outperformed- manipulation, epidurals, disc surgery, opioids,

exercise, radiofrequency denervation

ACUPUNCTURE

MECHANISM OF ACTION

SENSORY NERVE PATHWAYS

Acupuncture affects specialized nerve fibers (Aδ, Aβ, and C)

Also affects descending nerve pathways

DIRECT EFFECTS ON CNS

Spinal reflex- acupuncture stimulates muscle relaxation changes

in visceral organs

Brain

Change functional connectivity

Decreased activity in limbic structures

Associated with stress and illness

Improve regulation of hypothalamus pituitary adrenal axis

Modulate parasympathetic activity

PURINERGIC SIGNALING

Acupuncture elicits release of adenosine and ATP

Helps nerve transmission

Purine levels as background signal for healthy and damaged

tissue

2018: Huang, M, Wang, X, Xing, B, et.al.

Mice bred to not be able to bind to adenosine were found to

have no pain relief or any biological markers associated with

relief

BIOMOLECULES- SUBSTANCE P

Transmits pain information in to CNS

DeFelipe C, Herrero, JF, O’Brien, JA, Palmer, JA, Doyle CA, et.al.

(!998)

Donkin, JJ, Turner, RJ, Hassan, I, Vink, R (2007)

Electroacupuncture and Moxibustion

Down-regulates expression of Substance P in IBS patients

Donkin, JJ, Turner, RJ, Hassan, I, Vink, R (2007)

BIOMOLECULES- NITRIC OXIDE (NO)

Tsuchiya, M., Sato, E.,Inoue, M., Asada, A. (2007)

Local release of Nitric Oxide

Increase local circulation

ENDOGENOUS OPIOIDS

Electroacupuncture- increase in plasma or CSF

Activates endogenous opioid system and non opioid receptors

Part of response is antagonized by naloxone

ENDOGENOUS OPIOIDS (CONT)

Han, JS (2003)

Low-frequency (2Hz) “induces activation of mu- and delta-opioid

receptors”

Releases- enkephalin, beta-endorphins and endomorph

Supraspinal CNS regions

High frequency (100Hz)- dynorphin actions on kappa opioid

receptors in spinal cord

ENDOGENOUS OPIOIDS (CONT)

Harris, et al. (2009)

Acupuncture- short term increases in MOR binding potential

Long term increases in pain and sensory processing regions in the

brain

Absent in sham acupuncture

ACUPUNCTURE’S ANALGESIC

MECHANISMS

In animal models

Acu and electroacu- effective in alleviation of inflammatory, neuropathic, cancer-related and visceral pain

Triggers release of ATP and adenosine

Ascending neural pathways involving A-Beta, A-delta and C-sensory fibers

Mesolimbic analgesic loop in brain and brainstem

Descending pathway mechanisms

Dopamine, cytokine, glutamate, nitric oxide, GABA effects

Opioid neuropeptides- enkephalins, endorphins, dynorphins, endomorphins, nociception

Non-opioid neuropeptides- substance P, Vasoactive intestinal peptide, calcitonin gene-related peptide

ACUPUNCTURE AND MALADAPTIVE

NEUROPLASTICITY

Maladaptive neuroplasticity is challenge in pain management

Can be associated with sever chronic pain that is resistant to

treatment

Acupuncture may relieve symptoms

Evidence shows it may be able to reverse neuroplastic changes

in spine and somatosensory cortex

CARPAL TUNNEL AND

SOMATOSENSORY CORTEX

Maeda Y, Kim, H, Kettner, N, Kim, J, Cina, S, Malatesta, C, Gerber,

J, McManus, C, Ong-Sutherland, R, Mezzacappa, P, Libby, A,

Mawla, I, Morse, L, Kaptchuk, T, Audette, J, Napadow, V (2017)

“…acupuncture at local versus distal sites may improve median nerve function at the wrist by somatotopically distinct

neuroplasticity in the primary somatosensory cortex following

therapy. Our study further suggests that improvements in primary

somatosensory cortex somatotopy can predict long-term clinical

outcomes for carpal tunnel syndrome.

ADJUNCTIVE ACUPUNCTURE AND

OPIOID USE

Lin, JG, et al (2002) and Wang, B. et al (1997)

Decrease of more than 60% for post surgery pain

Xheng, Z., et al. (2008)

39% reduction in opioid like medication non-malignant pain

After acupuncture-

Lasted up to 8 weeks after treatments stopped

Tedesco, D. (2017

Reduction with the use of electroacupuncture

Acupuncture delayed opioid use

ADJUNCTIVE ACUPUNCTURE AND

OPIOID USE (CONT)

IN USAF medical center

Opioid prescriptions decreased by 45%

Muscle relaxants by 34%

NSAIDs by 42%

Benzodiazepines by 14%

Quality of life measurements showed statistically significant improvements

In elderly, falls from mental impairment

New Zealand Medical Journal: medication related harms-common and burdensome

ACUPUNCTURE AND OPIOID ABUSE

DISORDER

Chen, Z, Wang, Y, Wang R, Xie, J, Ren, Y (2018)

Acupuncture could be effective in treating OUD

Electroacupuncture

Alleviate symptoms of craving and depression

Can improve insomnia and anxiety

ACUPUNCTURE USE IN OPIATE

DEPENDENCE AND REHAB

Wen, et al. (1973)- Ear acupuncture alleviated opioid withdrawal

S/S

NADA- National Acupuncture Detoxification Association

established in 1985

Addresses…

acute and prolonged withdrawal symptoms

Stress and anxiety

Relapse

ACUPUNCTURE USE IN OPIATE

DEPENDENCE AND REHAB

Hu, et. al. (2009)- EA affects dopamine neurons

Improved harmful effects of opioid medication

Lee, et al.(2012)- EA can be used to decrease drug seeking

behavior in rats

We, et al. (1978)- Acu decreased biochemical stress markers

Chan, et al. (2014)

Decreased amount of morphine in treatment

Improved sleep

ACUPUNCTURE USE IN OPIATE

DEPENDENCE AND REHAB (CONT)

Meta analysis in 2012

“ the majority of studies agreed on the efficacy of acupuncture as

a strategy for the treatment of ‘opiate addiction’”

“neurochemical and behavioral evidence have shown that

acupuncture helps reduce the effects of positive and negative reinforcement involved in opiate addiction by modulating

mesolimbic dopamine neurons. Moreover, several brain

neurotransmitter systems involving opioids and GABA have been

implicated in the modulation of dopamine release by

acupuncture.”

SAFETY

Trial regarding chronic pain management: 454,920 patients with HA, LBP and/or osteoarthritis

Minor adverse reactions: needling pain, hematoma, bleeding

7.9%

Serious adverse reactions: pneumothorax, acute hyper- or hypo-tensive reactions, erysipelas, asthma, aggravation of suicidal thoughts

.003%n (13 patients)

Feasibility study

Feasible, safe and acceptable in an ICU setting

Systematic review

Performed by trained practitioners using CNT

Literature- acupuncture with cancer patients with low risk

COST-EFFECTIVENESS

Systematic review of 8 cost-utility and cost-effectiveness studies

Cost per quality adjusted life year gained below threshold for “willingness to pay”

LBP, neck pain, dysmenorrhea, migraine, HA and osteoarthritis

Cost-effectiveness analysis of osteoarthritis of knee

Acupuncture was most cost effective option

Full insurance coverage for acupuncture…

Increase premium from $.38 to $.76

Save $35,480 for migraine, $32,000 for angina pectoris, $9,000 severe osteoarthritis and $4,246 for carpal tunnel

ACUPUNCTURE EVIDENCE PROJECT-

CONDITIONS WITH DEMONSTRATED COST-

EFFECTIVENESS

Allergic rhinitis

LBP

Ambulatory anashthesia

Migraine

Chronic pain

Depression

Osteoarthritis

Dysmennorhea

Post op N/V

Headache

MARKUS MUNGER, PT

CRED. MDT

Owner Munger Physical Therapy 2008

Multiple lectures on Spine pain, athletic injury and Rehab, Fall/ Balance Rehab, and benefit of LSVT with PD

Physical Therapist for 30 years

OBJECTIVES

The science behind pain

Pain vs Function

Pain vs performance

Current research

Mechanical assessment: reproduce vs reduce

Acute/ Sub-acute/ Chronic

Benefits of Physical Therapy

Benefits of exercise prescription

IS PAIN AN

INJURY?

IS PAIN AN INJURY? REALITY

No Pain No Tissue Injury

No Pain Tissue Injury

Pain No Tissue Injury

Pain Tissue Injury

MISCONCEPTIONS Pain is bad

Pain indicates something damaged or harmed

Pain needs to be abolished before engaging in

normal activity and movement

Passive treatment is the answer

Pain will increase with all movement

Work is potentially harmful

ACUTE AND SUB ACUTE

PAIN

CHRONIC

PAIN

Serves no biologic purpose

No recognizable end point

Disease state that can persist for months or years

CHRONIC PAIN

CREATES

DEPENDENCE ON

MEDICATIONS

Greater than 12

weeks.

HOW DO WE

MANAGE

PAIN

YELLOW FLAGS OF PATIENT MANAGEMENT

Attitudes Belief Compensations

Dx EmotionsFamily (and

Friends)

NUMERICAL PAIN RATING SCALE

(NPRS)

1. 0-2 Safe

2. 2-5 Acceptable

3. 5-10 High risk

Pain is allowed to reach a 5

Pain after completion of activity is

allowed to reach a 5

Pain in morning should not exceed a 5

Pain and stiffness is not allowed to

increase from week to week

Adapted from Silbernagel & Crosley, JOSPT, 2015

THE WILK CLASSIFICATION SYSTEM

___Stage Definition Red Flag

1 Pain upon Exertion Pain that alters Mechanics

2 Pain @ Rest Pain that prevent rest

3 Pain with ADLs Avoidance of ADLs

4 Pain Managed with Meds Being in Stage 4

5 Crippling pain Being in Stage 5

HOW CAN PHYSICAL

THERAPY HELP?

THE RESEARCH

PT and Yoga

Chronic back pain

OA of knees

Before and after surgery

Arthritis

OPIOIDS AND

Low back pain

After surgery

Arthritis

PHYSICAL THERAPY

Collaboration with:

Patients

Families

Professionals

Payers

WHEN TO SEND

Mechanical pain: or changes with position or movement

Acute/ Chronic injuries

Pain that does not resolve with OTC medications

When personalized care is needed to meet your patient's needs

To empower patients to be active participants in their care

To reduce opioid dependence

Conservative, non-surgical care

Inability to return to work or sport

PHYSICAL

THERAPY:

A SOLUTION

Evaluation

Proper exercise prescription

based on patients' level

Assessing patient's motivation to

get better

Education of pain and the

process

MECHANICAL ASSESSMENT

Does pain change with movement

Does pain change with change in position

Peripheralized vs Centralized

Does pain return to baseline or better

RED YELLOW GREEN

EXERCISE

PRESCRIPTION

Develop/ Administer/ Modify/ Progress

Poor conditioning/ impaired strength/

Musculoskeletal imbalance/

deficiencies

Individuals that exercise regularly will

experience less pain

MUSCLE MASS

NATIONAL GUIDELINES FOR PHYSICAL

ACTIVITY

THESE ARE THE MINIMUM GUIDELINES

Children / Adolescents: Ages: 6-17

60+ minutes daily

Moderate / vigorous aerobic activities

Muscle strengthening activities

Bone strengthening activities

Adults: Ages: 18-64

Weekly

Aerobic activities (10+ minute bouts)

150 minutes moderate intensity

75 minutes vigorous intensity

An equivalent combo of both

Muscle strengthening activities 2+ days

“THE MAIN IDEA BEHIND THE GUIDELINES IS THAT

REGULAR PHYSICAL ACTIVITY OVER MONTHS

AND YEARS CAN PRODUCE LONG-TERM

HEALTH BENEFITS. ”

Published by the US Dept, of Health and

Human Services (DHHS) in 2008

MANUAL THERAPY

Hands on manipulation of joints/

tissue

Modulate pain, reduce swelling,

reduce inflammation

Improve mobility

STRESS MANAGEMENT

Mindfulness

Relaxation

Visualization

Biofeedback

SLEEP DISTURBANCE DUE TO PAIN

Sleeping postures

Pre sleep stretch

Deep breathing/ Relaxation

PAIN NEUROSCIENCE

EDUCATION

SUMMARYWilk

classification 4Pain does not stay below a 5

Compensation with

movement

Patient says so: A B C

FUNCTION ECCENTRIC VS

PAIN ECCENTRIC

REFERENCES

1. Beyond Opioids: How Physical Therapy Can Transform Pain Management and improve Health: American Physical Therapy Association 2. Wroblewski AP, Amati F, Smiley MA, et al. Chronic Exercise Preserves Lean Muscle Mass in Masters Athletes. The Physician and Sports Medicine, 2015;39:3 (172-178) doi: io.38io/psm.2oi

1.09.19333. IASP Taxonomy. Webpage. International Association for the Study of Pain. Last updated December 14, 2017. https://www.iasp-pain.org/Taxonomy#Pain. Accessed April 2, 2018.4. Holth HS, Werpen HKB, Zwart J-A, Hagen K. Physical inactivity is associated with chronic musculoskeletal complaints 11 years later: results from the Nord-Trøndelag Health Study. BMC

Musculoskelet Disord. 2008;9:159. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2606680/. Accessed April 2, 2018.5. Fernández-de-Las Peñas C, Ortega-Santiago R, de la Llave-Rincón AI, et al. Manual Physical therapy versus surgery for carpal tunnel syndrome: a randomized parallel-group trial. J Pain.

2015;16(11):1087-94. https://www.ncbi.nlm.nih.gov/pubmed/26281946. Accessed April 2, 2018.6. Delitto A, George SZ, Van Dillen L, et al. Clinical practice guidelines linked to the International Classification of Functioning, Disability, and Health from the Orthopaedic Section of the American

Physical Therapy Association. J Ortho Sports Phys Ther. 2012;42(4):A1-57. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4893951/. Accessed April 2, 2018.7. Okifuji A, Hare BD. The association between chronic pain and obesity. J Pain Res. 2015;8:399-408. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4508090/. Accessed April 2, 2018.8. Finan PH, et al. The association of sleep and pain: an update and a path forward. J Pain. 2013;14(12):1539-15529. Hayden JA, van TUlder MW, Malmivaara A, Koes BW. Exercise therapy for treatment of non-specific low back pain. Cochrane Database Syst Rev. 2005;Jul 20(3):CD000335.

https://www.ncbi.nlm.nih.gov/pubmed/16034851. Accessed April 2, 2018.10. Mover R, Ikert K, Long K, Marsh J. The value of preoperative exercise and education for patients undergoing total hip and knee arthroplasty: a systematic review and meta-analysis. JBJS Rev.

2017;5(12):e2. https://www.ncbi.nlm.nih.gov/pubmed/29232265. Accessed April 2, 2018.11. Fransen M, McConnell S, Hernandez-Molina G, Reichenbach S. Exercise for osteoarthritis of the hip. Cochrane Database Syst Rev. 2014;22(4):CD007912.

https://www.ncbi.nlm.nih.gov/pubmed/24756895. Accessed April 2, 2018.12. Messier SP, Mihalko SL, Legault C, et al. Effects of intensive diet and exercise on knee joint loads, inflammation, and clinical outcomes among overweight and obese adults with knee

osteoarthritis: the IDEA randomized clinical trial. JAMA. 2013;310(12):1263-73. https://www.ncbi.nlm.nih.gov/pubmed/24065013/. Accessed April 2, 2018.13. Deyo RA, Von Korff M, Duhrkoop D. Opioids for low back pain BMJ. 2015;350:g6380. http://www.bmj.com/content/350/bmj.g6380. Accessed April 2, 2018.14. Brummett CM, Waljee JF, Goesling J, et al. New persistent opioid use after minor and major surgical procedures in US adults. JAMA Surg. 2017;152(6):e170504.

https://jamanetwork.com/journals/jamasurgery/articleabstract/2618383?redirect=true. Accessed April 2, 2018.15. Ivers N, Dhalla IA, Allan GM. Opioids for osteoarthritis pain: benefits and risks. Can Fam Physician. 2012;58(12):e708. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3520677/. Accessed April 4,

2018.

FAILURE OF OTHER

MODALITIES:

MANAGING PAIN

WITH MEDICATION

Dr Nick Reina

EVALUATE

HISTORY AND PHYSICAL

DOCUMENTATION/ TEST RESULTS

SCREENING ORT PHQ-9

DOSING

Morphine mg Equivalent

Codeine 6:1

Hydrocodone 1:1

Oxycodone 1:1.5

Fentanyl 2.4ug:1

Oxymorphone 1:3

Hydromorphone 1:4

FOLLOW UP /

SURVEILLANCE

Prescription Profiling / MAPS

Drug Testing

Pill Counts

Benefit tools

Oswerky (function)

Quality of life Surveys

Meaningful use/ Rechecks every 3 months

QUESTIONS?