ULRICH TACKEUNIVERSITY OF KUOPIO

FINLAND

Is there a place for complementary and alternative methods in the

treatment of addiction?

Alternernative and complementary methods – a Finnish/German perspective

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� Germany: ”Heilpraktikergesetz” (1939)� Finland: ”Puoskarilaki” (in preparation)� Role of alternative treatment methods in society:¡ minor in Finland in comparison to Germany, where¡ ”Schulmedizin” vs. ”alternative Heilmethoden”¡ E.g. in Germany 60.000 medical doctors prescribe

homeopathic or ”natural” preparations regularly (Der Spiegel 21/2008)

• 2008: chair of complementary medicine at the CharitéBerlin

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Attitudes concerning alternative treatment methods in a sample (N=1005) of the Finnish population

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� ”Are the following methods capable of improving disease(s)?”

� Acupuncture yes 64, no 11, can’t tell 25� TCM 39 28 34� Homeopathy 36 27 38� Hypnosis 32 16 52� Aromatherapy 24 20 56

Miscellaneous treatments: sporadically mentioned in the literature, no good-quality clinical studies

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� aromatherapy� spiritually-focused group therapy¡ high placebo-effect

� hypnosis¡ used in tobacco-addiction already in 1847 ¡ problems with research:÷difficult to standardize÷difficult to find control-treatment (placebo)

¡ Review by Villano et al. (Med. Clin. N Am. 88 (2004) 1607-1621: ”the evidence of any effect is anecdotal”

Homeopathy in addiction treatment

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� scientific basis highly questionable¡ ”high-potency” dilutions do not contain a single molecule

of active substance� ”very much of the effect of homeopathy is related

to other factors, e.g. the context… the medication is only a small part” (Claudia Witt)� very few studies on homeopathy in addiction

treatment ¡ published in ”alternative medical journals” (scientific

standards? peer-reviewed?)

� no meta-analysis, no reviews

Acupuncture

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� Main types :� Traditional Chinese (whole body) acupuncture¡ causing feeling of de qui¡ influencing ”fundamental body-energy”

� Auricular acupuncture (PMF Nogier) ¡ underlying hypothesis: different internal organs represented in

different places of the outer ear ¡ application: mono- or bilateral, with or without electrical or

manual stimulation¡ ”exported” to China

Acupuncture in addiction treatment

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� Mostly auricular (ear) acupuncture¡ Europe, US, China¡ clear negative statement in the Finnish National

Treatment Guidelines (”Käypä Hoito”)¡ controversal among ”opinionleaders”¡ debate ongoing � Search of the literature:� experimental animal studies� clinical studies � meta-analyses

Examples of experimental studies in rats and humans on acupuncture on withdrawal symptoms

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� Studies in rats: Stimulation of specific points (e.g. HT7 vs. ST36)¡ Prevention of decrease of extracellular dopamine in

the accumbens (ethanol-w.). Rong Jie Zhoa et al, 2006¡ Attenuation of CRF mRNA increase and anxiety

(nicotine-w.). Younbyoung Chae et al, 2008

� Human studies: Functional MRI (fMRI)¡ Activation of hypothalamus after acupuncture in relation

to dequi-score (heroin addicts). Sheng Liu et al. 2007

Individual differences in the deqi scores are critical variable for the detection of the hypothalamus activation during acupuncture stimulation. (A) AFNI whole-brain, voxel-wise t-map image of group differences depicting greater activation of the right hypothalamus in heroin addicts (vs. healthy controls) during acupuncture stimulation. (B) Regression plots showing correlation (r=0.67, P<0.05) of deqi scores with the activated voxel rate in the hypothalamus (red circle, the heroin addicts: green circle, the healthy subjects).Viite: Liu S et al. Neuroscience Letters (2007) 421:203-208Tacke 9/2008 11

What to make out of the data from experimental neurobiological research on acupuncture ?

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¡ mostly from Korean and Chinese research centres¡ some published in Western peer-reviewed journals with

notable impact factors (e.g. Brain Research, Neuroscience Letters)

¡ reported neurobiological changes ”make sense”, being in line with accepted neurobiological theories of addiction and withdrawal

� remaining questions:¡physiological basis of acupuncture?¡acupuncture in animals vs. auricular

acupuncture in humans?

And what about the clinical data?

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Clinical studies on acupuncture

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� From Asian and western reasearch centres� Studied in treatment of withdrawal from¡ Nicotine¡ Alcohol¡ Opiate¡ Cocaine

Summary and meta-analysis of studies of acupuncture versussham acupuncture for effectiveness in smoking cessation

L.M. Villano, A.R. White: Med Clin N Am 88 (2004) 1607-1621Tacke 9/2008 15

Summary from 14 studies on acupuncture in smoking cessation (Cochrane Review 2002)

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� 12 studies: no difference� 2 studies with positive results:¡ Lacroix and Besancon (1977)÷”French facial points, insertion at moment of

inspiration, anticlockwise twist. Controls at sham points÷OR 6.02 (95% CI 2.92, 12.41)

¡ He et al (2001)÷Ear acupressure with semipermanent ”seeds”

(buttons)÷OR 7.70 (95% CI 1.55, 38.35)

Meta-analyses and reviews of acupuncture for cocaine and opiate addiction

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� D’Alberto A. Auricular acupuncture in the treatment of cocaine/crack abuse: a review of the efficacy, the use of the NADA*-protocol, and the selection of sham points.(Journal of Alternative and Complementary medicine (2004) Dec;10(6):985-1000.

� Smith GS, Foxcroft DR. Auricular acupuncture for cocaine dependence The Cochrane Collaboration 2008 Jordan JB. Acupuncture treatment for opiate addiction: A systematic review.Journal of Substance Abuse Treatment 30 (2006) 309-314.

� Jordan JB. Acupuncture treatment for opiate addiction: A systematic review. Journal of Substance Abuse Treatment 30 (2006) 309-314.

÷ (*=National Acupuncture Detoxification Association)

Conclusions from recent reviews and meta-analyses

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� D’Alberto (2004) 6 RCTs ”This review could not confirm that acupuncture was an effective treatment for cocaine abuse.”

� Smith & Foxcroft (2008) . 11 RCTs. ”There is noevidence that auricular acupuncture is effective as a treatment for cocaine dependence.”

� Jordan (2006) Literature review 1973-2006. 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.”

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What do we make out of all this?

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� we have to live with the fact, that people believe in treatments, which do not have a scientifically verified therapeutic effect� most (if not all) of the perceived effects

relate to the therapist, setting, patients hopes and convictions to get better. ”Potentiation of placebo-effects”� listening to, and understanding, the drug-

dependent patient should be the major goal of the clinician and an integral part of normal medical practice (”Schulmedizin”)!

Suggestion for a resolution and final conclusion

� Combining the quest for evidence-based treatment with pragmatism� Is there a place for these treatments in

addiction? ¡ No, as far as publicly funded services are concerned¡ Maybe yes for privately run services, where (ideally) the

client (patient)÷decides himself about the suitability of the

treatment, and÷pays for it himself/herself

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And last, but not least:

� In Finland, we need a law, which enables health-care authorities to control the activities of the alternative and complementary treatment sector:� in preparation� Similar to the Swedish ”kvaksalver”-law and the

German ”Heilpraktiker-Gesetz”?

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