Is there a place for complementary and alternative methods in the treatment of addiction? ULRICH TACKE UNIVERSITY OF KUOPIO FINLAND

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1 Is there a place for complementary and alternative methods in the treatment of addiction? ULRICH TACKE UNIVERSITY OF KUOPIO FINLAND

2 Alternernative and complementary methods a Finnish/German perspective 2 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 medical doctors prescribe homeopathic or natural preparations regularly (Der Spiegel 21/2008) 2008: chair of complementary medicine at the Charité Berlin

3 3

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5 Attitudes concerning alternative treatment methods in a sample (N=1005) of the Finnish population Are the following methods capable of improving disease(s)? Acupuncture yes 64, no 11, can t tell 25 TCM Homeopathy Hypnosis Aromatherapy

6 Miscellaneous treatments: sporadically mentioned in the literature, no good-quality clinical studies 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) : the evidence of any effect is anecdotal 6 Tacke inhibition of 9/2008

7 Homeopathy in addiction treatment scientific basis highly questionable 7 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

8 Main types : Acupuncture Traditional Chinese (whole body) acupuncture causing feeling of de qui influencing fundamental body-energy Auricular acupuncture (PMF Nogier) 8 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

9 Acupuncture in addiction treatment 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 9

10 Examples of experimental studies in rats and humans on acupuncture on withdrawal symptoms Studies in rats: Stimulation of specific points (e.g. HT7 vs. ST36) 10 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

11 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: Tacke Liu 9/2008 S et al. Neuroscience Letters (2007) 421:

12 What to make out of the data from experimental neurobiological research on acupuncture? 12 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?

13 13 And what about the clinical data?

14 Clinical studies on acupuncture From Asian and western reasearch centres Studied in treatment of withdrawal from Nicotine Alcohol Opiate Cocaine 14

15 Summary and meta-analysis of studies of acupuncture versus sham acupuncture for effectiveness in smoking cessation L.M. Villano, A.R. White: Med Clin N Am 88 (2004)

16 Summary from 14 studies on acupuncture in smoking cessation (Cochrane Review 2002) 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) 16

17 Meta-analyses and reviews of acupuncture for cocaine and opiate addiction 17 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): 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) Jordan JB. Acupuncture treatment for opiate addiction: A systematic review. Journal of Substance Abuse Treatment 30 (2006) (*=National Acupuncture Detoxification Association)

18 Conclusions from recent reviews and metaanalyses 18 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 no evidence that auricular acupuncture is effective as a treatment for cocaine dependence. Jordan (2006) Literature review 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.

19 19

20 What do we make out of all this? 20 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 drugdependent patient should be the major goal of the clinician and an integral part of normal medical practice ( Schulmedizin )!

21 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 21 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

22 And last, but not least: In Finland, we need a law, which enables healthcare 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? 22

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