The effectiveness of treating abstinence syndrome by acupuncture over traditional medication and psychotherapy

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1 Title The effectiveness of treating abstinence syndrome by acupuncture over traditional medication and psychotherapy Author(s) Lau, Kiu-yung, Helen; 劉 翹 溶 Citation Issued Date 2014 URL Rights The author retains all proprietary rights, (such as patent rights) and the right to use in future works.

2 Abstract of project entitled The effectiveness of treating abstinence syndrome by acupuncture over traditional medication and psychotherapy Submitted by Lau Kiu Yung Helen for the degree of Master of Public Health at The University of Hong Kong in August 2014 Background Traditional medication therapy and psychotherapy are commonly used for treatment drug abstinence syndrome. Because of the side effects of traditional medication therapy (MT), acupuncture therapy (AT) is under investigation for treating abstinence syndrome, particularly for heroin detoxification. This project aims to review different randomised clinical trials (RCTs) of heroin detoxification treatment by acupuncture, and retrieve relevant data so that appropriate suggestions can be made to the Narcotics Division (ND), the Department of Health (DH), non-governmental organisations (NGOs) and related local public health institutes for the anti-drug services of heroin and opioid drugs. i

3 Methods A systematic review was conducted using PubMed and Google Scholar to retrieve 13 relevant articles of randomised clinical trials (RCTs) in English and Chinese conducted from 2000 to These RCTs contained data of heroin-dependent patients, details of assessment of abstinence syndrome and treatments; and comparison of efficacy of AT with MT, such as side effects, severity and relapse of heroin abstinence in physical and psychological aspects. Results 13 articles were included. All treatments were conducted in clinics or hospitals. Different intervention strategies were included, comparing AT with MT, AT plus MT with MT alone, AT with no treatment as well as true AT with superficial AT. All trials have reported better therapeutic effects in the heroin abusers with AT, regardless the use of medication, age and sex. Improved treatment effects were demonstrated in reducing psychological effect of heroin abstinence, such as anxiety and depression, sleep quality, relapse and heroin craving. Also, improved treatment of physical effects of abstinence was shown by increasing body weight, improved liver and kidney functions, improved immunity and lower adverse effects than conventional MT. No adverse effect was reported in 3 trials (23%) or mentioned in 9 trials (69%), mild adverse effects was reported in 1 trial. Conclusions ND, DH, NGOs and other local public health institutes should conduct further studies in Hong Kong to obtain primary local data of the therapeutical effects of AT, and implement AT as an adjunct to the traditional MT and psychotherapy for treating heroin abstinence syndrome due to it high efficacy, safety and low side effects. ii

4 Keywords: acupuncture, heroin detoxification, randomised clinical trial, withdrawal syndrome, abstinence iii

5 The effectiveness of treating abstinence syndrome by acupuncture over traditional medication and psychotherapy by Lau Kiu Yung Helen B. Sc. H.K. A project submitted in partial fulfilment of the requirements for The Degree of Master of Public Health at The University of Hong Kong. August 2014 iv

6 Declaration I declare that the project and the research work thereof represent my own work, except where due acknowledgement is made, and that it has not been previously included in a thesis, dissertation or report submitted to this University or to any other institution for a degree, diploma or other qualifications. Signed Lau, Kiu Yung Helen v

7 Acknowledgements I would like to thank my supervisor Dr. Eric Lau for his invaluable advice and comments on this Project. I also wish to acknowledge my friend, Lucy Tse, as a Chinese medicine doctor for her advice on the use of acupuncture for treating heroin abstinence syndrome. vi

8 Contents Abstract... i Declaration... v Acknowledgements... vi Illustrations... ix Abbreviations... x Chapter 1 Background Drug abuse in Hong Kong Abstinence syndrome of the heroin abusers Conventional treatment offered by the government for heroin abusers Use of acupuncture in treatment of heroin abstinence syndrome Aims and objectives... 4 Chapter 2 Methods Search strategy Target outcomes for retrieval Inclusion criteria Exclusion criteria... 6 Chapter 3 Results Selection of studies Summary of studies Outcome efficacy and safety assessment Summary of efficacy and adverse effect of studies Chapter 4 Discussion Efficacy of acupuncture on treating heroin abstinence syndrome Limitations of the review vii

9 4.3 Implications of the review Suggestions for ND, DH, NGOs and other local public health institutes for anti-drug services Chapter 5 Conclusions Appendix Data abstraction of the 13 RCTs References viii

10 Illustrations Figure 1 Process of literature search... 7 Table 1 Summary of RCTs on heroin detoxification by acupuncture ix

11 Abbreviations AT CINA Scale DH HA HAMA Scale HAMD Scale MDT MMT MT ND NGOs OWS PSQI RCT s SARDA Acupuncture Therapy Clinical Institute Narcotic Assessment System Scale Department of Health, Hong Kong SAR Hospital Authority Hamilton Anxiety Scale Hamilton Depression Rating Scale Methadone Decrescendo Therapy Methadone Maintenance Treatment Medication Therapy Narcotics Division, Security Bureau Non-governmental Organisations Opiate Withdrawal Scale Pittsburgh Sleep Quality Index Randomised Clinical Trials Society for the Aid and Rehabilitation Abusers, Caritas - Hong Kong TCM Traditional Chinese Medicine x

12 Chapter 1 Background 1.1 Drug abuse in Hong Kong In Hong Kong, according to the data from the Narcotics Division of the Security Bureau (ND) 1, the drugs most commonly abused in Hong Kong are heroin and psychotropic substances, for example, ketamine, methylamphetamine(ice), triazolam / midazolam / zopiclone, cocaine, cough medicine, cannabis, nimetazepam and MDMA(ecstasy) in Referring to the information from the ND in 2012, for all age groups and both sexes, more than three-quarter of the drug abusers are previously reported drug abusers 2, reflecting the high relapse rate of drug abusers. Most respondents of the drug abusers surveyed from drug treatment and rehabilitation centres 2, counselling centres for psychotropic substance abusers 2, and centres for drug counselling of non-governmental organisations (NGOs) 2 revealed that, the reasons for drug abuse were due to thoughts of relief of boredom, peer influence, avoidance of discomfort of the absence of the drug and curiosity 2. Therefore, psychological factors are also a major drive for people to abuse the drugs. 1.2 Abstinence syndrome of the heroin abusers Abstinence syndrome, occurs in individuals who suddenly discontinue or reduce in intake of medications, recreational drugs or certain chemical substances with continuous administration previously, bringing about both physical dependence and withdrawal syndrome 3. As mentioned in 1.1, most drug abusers are previously reported drug abusers, which means, the conventional treatment offered by the government is inadequate for eliminating the drug abstinence syndrome of the patients. Opioid drugs, such as heroin, morphine, cocaine, methadone, etc., are a 1

13 major group of drugs being abused by the drug addicts 3,4. Consequently, the anti-drug services are mainly aimed at treating abstinence syndrome caused by opioids. Taking heroin as an example, the abstinence syndrome is significant. Physical dependence is expected when the drug is stopped abruptly after 2 to 10 days of continuous use 3. For withdrawal syndrome of heroin, some autonomic symptoms, such diarrhoea and rhinorrhoea (running nose), nausea and emesis, etc., may be shown. Plus, withdrawal of heroin will arouse the central nervous system, leading to sleeplessness, different kinds of discomforts, like spasm of abdomen, pain in bones and muscles, and strong desire for drugs 3. The failure of complete rehabilitation of the heroin abusers is probably attributed to these physical and psychological responses of abstinence syndrome. 1.3 Conventional rehabilitation service for heroin abusers The rehabilitation services offered by the government for the heroin users include: Out-patient Methadone Treatment Programme 5, Voluntary In-patient Treatment 5, Residential Drug Rehabilitation Programmes 5 and Substance Abuse Clinic Centre for Drug Counselling 5. The out-patient methadone treatment programme is run by the Department of Health (DH), providing both methadone maintenance and methadone detoxification programmes 5. The voluntary in-patient / residential drug rehabilitation programmes 5 are operated by the Caritas - Hong Kong, the Society for the Aid and Rehabilitation Abusers (SARDA) 5, the Hong Kong Christian Service and Christian therapeutic agencies 5, which serves the drug abusers who intend to pursue treatment with living spaces, restoration and acceptance of the society 5. 2

14 The substance abuse clinics are operated by the Hospital Authority (HA) 5, which provide services to cases from the counselling centres for psychotropic substance abusers, voluntary agencies and other health care providers 5. Also, opioid and psychotropic substances abusers can join other services of drug detoxification, counselling and psychotherapy according to their will 5. From the above mentioned, the available anti-drug psychotherapy is a supplementary service, while Medication Therapy (MT) is the main traditional treatment provided by the anti-drug institutes. The available methadone treatments for heroin abusers, which are Methadone Maintenance Treatment (MMT) and Methadone Decrescendo Therapy (MDT), may lead to health concerns of the drug users 3. Methadone works to reduce the chance of self-administration of opioids by alleviating the desire for opioid drugs 5. Patients may sustain the MMT if they are unable to cease the medication, or to be abstained from the progressive decrease in methadone dosage 5. MMT requires more than 80 mg of methadone daily for substituting the effects of heroin, which is also the dosage demanded by methadone abusers 5. Although a low-dose of methadone is used in MDT, which may reduce its health hazards and the tendency of addiction, individuals treated with low-dose methadone may show discomforts such as nausea, vomiting, dizziness, mental clouding, anxiety, ecstasy, constipation, difficulty in breathing, drying of respiratory secretions, sweating, etc., which are possibly more significant than other opioid drugs if improper dosage of methadone is used Use of acupuncture in treatment of heroin abstinence syndrome Due to the observed adverse effects of MMT and low efficacy of psychotherapy, another aspect with the use of acupuncture therapy (AT), is under investigation for treating heroin abstinence syndrome over years In Hong Kong, starting from 1977, 3

15 Dr. H.L. Wen treated abstinence syndrome of heroin with acupuncture successfully for the first time 6. This gives rise to more and more clinical trials and analysis in Hong Kong, for example, by the Beat Drug Fund of Hong Kong Government 3, to explore the efficacy and safety of acupuncture for heroin detoxification, and a hope for heroin and opioid addicts to be detoxified from opioid abstinence syndrome completely Aims and objectives Heroin and opioid abuse in Hong Kong is a major concern of the drug abuse problem in Hong Kong. Still, there are only MT and psychotherapy available as the rehabilitation services, with limited capacity and efficacy. And also, long-term use of MT deteriorates users health. As the higher efficacy of AT is shown in various studies, the aim of this project is to review studies involving different types of AT with or without MT, in order to retrieve relevant data of the efficacy of the treatment of abstinence syndrome, mainly heroin, by AT, and its mechanism of heroin detoxification with the least use of MT, so as to provide the ND, the DH and the relevant local public health institutions with proper recommendations to adopt acupuncture and appropriate anti-drug services to the heroin and opioid abusers with the least sacrifice of their health. 4

16 Chapter 2 Methods 2.1 Search strategy The search of relevant literature was done with the use of PubMed and Google Scholar to retrieve relevant articles which describe randomised clinical trials (RCTs) of acupuncture to treatment heroin abstinence syndrome for recent 15 years, from 2000 to Different combinations of key words were used during the systematic review, including acupuncture and heroin detoxification and randomised clinical trial and (withdrawal syndrome or abstinence). Articles were excluded if they did not satisfy the inclusion criteria or met any of the exclusion criteria during screening of the titles and/or abstracts. 2.2 Target outcomes for retrieval RCTs which contained data of heroin-dependent patients, details of assessment of abstinence syndrome and treatments; and comparison of efficacy of AT with MT, such as side effects, severity and relapse of heroin abstinence in physical and psychological aspects, with description of the outcome measures, such as different self-developed scales for detoxified or improved patient number, clinically used heroin abstinence scales, methadone dosage, relapse rate, change in health status of participants of heroin abstinence were retrieved. 2.3 Inclusion criteria Articles which contain description of the original empirical data of the RCTs, the detailed method or type of acupuncture, the comparison with at least 1 control group, and at least 10 participants in each treatment group were included. Articles in English 5

17 as well as Chinese were reviewed as many studies of acupuncture for heroin detoxification were conducted by Chinese institutes. Only the articles with the full text will be evaluated in-depth. 2.4 Exclusion criteria Irrelevant, non-target types of publications such as editorials, letters or opinions were excluded from the review. Publications with secondary sources of information, such as guidelines and reviews, which providing data originated from other studies were excluded from the literature review. Articles without full text or data were excluded. 6

18 Chapter 3 Results 3.1 Selection of studies By utilising different combination of search terms, 322 potentially relevant articles were initially identified. After screening for the titles and the abstracts, 277 articles not relevant or not containing full text were excluded. 45 articles were retained for in-depth evaluation for their relevance to this project. Finally, 32 articles were excluded due to the absence of full text or data, or subjective information. 13 articles of RCTs were included for review. The process of literature search is shown in figure 1 below. Figure 1 Process of literature search Pubmed / google scholar: Acupuncture AND Heroin detoxification AND Randomised Clinical Trial AND (Withdrawal Syndrome or Abstinence) Initial search: 322 Potentially relevant articles identified In-depth evaluation: 45 potential relevant articles included Final literature review: 13 articles included Excluded: 94 articles were not relevant based on the title and 183 did not have full text Excluded: 3 did not contain empirical data, 5 were not relevant based on the abstract and 24 contained any of the exclusion criteria 7

19 3.2 Summary of studies 13 articles describing 13 RCTs were included. All participants were treated on an inpatient basis. Different types of acupuncture were used in these RCTs. 8 trials (62%) employed electroacupuncture, the electrical stimulation into the acupoints 8,9,12,14,15,17-19 ; 4 trials (31%) used acupuncture, the insertion of needles into the acupoints 7,10,11,13, and 2 trials (15%) used auricular plaster, a plaster placed on auricular acupoints with stimulation by pressing 16,17. For the stimulation of the body parts, 11 trials (85%) stimulated the acupoints on the body 7-10,12-15,17-19, 4 trials (31%) stimulated the acupoints on the ears 11,16,17,19, 1 trial (8%) stimulated the acupoints on the scalp and the body 15. The course of acupuncture treatment was less than 10 days in 2 trials (15%) 7,10, 10 to 20 days in 7 trials (54%) 7,10,12-16, 21 to 30 days in 4 trials (31%) 11,17,18. To compare the effectiveness of AT with MT, 8 trials (62%) used methadone as controls 8,10-13, However, there are other medications included as control treatments, 1 trial (8%) used Chinese patent medicine Kuai Su Wu Yin Jie Du Pian ( 快 速 無 癮 戒 毒 片 ) 7 ; 2 trials (15%) used western medications other than methadone as control, including diazepam 9 and lofexidine 14. No placebo was used in the 13 RCTs. A summary of the 13 RCTs included on heroin detoxification is presented in Table 1. Details of each RCT are shown in the Appendix. 3.3 Outcome efficacy and safety assessment Referring to the 13 included RCTs, the study on efficacy and safety of acupuncture for heroin detoxification can be categorised into 4 types in terms of different treatment strategies: comparing AT with MT (2 trials, 15%) 7,14 ; comparing AT plus MT with MT alone (9 trials, 69%) 8-13,15-17 ; comparing AT with no treatment (1 trial, 8%) 18 ; and comparing true AT with superficial AT (1 trial, 8%) 19. All clinical outcomes in the 13 8

20 RCTs were measured and analysed by health practitioners or specialists in research. In 6 trials (46%) of the 13 trials, the severity of heroin abstinence syndrome was measured by different self-developed scales for detoxified patient number 7 or improved patient number 10,11,13,16,17. For assessment scales for heroin abstinence severity, 3 trials (23%) employed Hamilton Anxiety Scale (HAMA Scale) 8,10,18 ; 3 trials employed Himmelsbach score 9,12,15 ; 2 trials (15%) employed Clinical Institute Narcotic Assessment Scale (CINA Scale) 13,14 ; 1 trial (8%) employed Hamilton Depression Rating Scale (HAMD Scale) 8 ; 1 trial (8%) employed Opiate Withdrawal Scale (OWS) 17 ; 1 trial (8%) employed Pittsburgh Sleep Quality Index (PSQI) scores 19. Other assessments include methadone dosage 8, patients' body weight 9, urine morphine test 9, blood test 10,14, adverse effect 12, liver and kidney function tests 14, relapse rate 16 and self-developed heroin craving score 19. For the scope of assessment in different measurements of abstinence syndrome of heroin, the HAMA scale is a questionnaire which assesses the psychological changes of patients in aspects of depression and anxiety by clinicians 20. The Himmelsbach score is assessed by clinical observations of various physical symptoms of abstinence syndrome, like changes in blood pressure and breathing rate, pupil dilation, fever, etc 22,23. The CINA scale is assessed by opioid withdrawal signs and physical symptoms, such as changes in heartbeat rate and blood pressure and other observed physical items 21. The HAMD scale makes use of a questionnaire to assess degree of patients depression by examining emotion, suicidal tendency, sleeplessness, tardiness, anxiety, weight reduction, and other physical symptoms 22. The OWS scale is a clinician-administered scale for assessing a patient's level of physical dependence on opioids by evaluating 21 common withdrawal signs 17. The PQSI scores are obtained by a self-graded questionnaire evaluating sleep quality and disorders with different 9

21 component items over 1 month 23. Other measurements in physical detoxification of heroin included the duration and dosage of methadone used in improved patients 8,10-13,15-17, in terms of patients body weight 9, functions of liver and kidneys 14, blood tests for immunoglobulins 10,14 and adverse effects 12. Psychological effects of abstinence syndrome were also measured by relapse rate 16 and self-developed heroin craving score Summary of efficacy and adverse effect of studies All 13 RCTs with different treatment strategies, comparing AT with MT, AT plus MT with MT alone, AT with no treatment as well as true AT with superficial AT, have reported greater or similar therapeutical effects in the heroin abusers with AT, regardless the use of medications, age and sex. Improved treatment effects were demonstrated in reducing psychological effect of heroin abstinence, such as anxiety and depression 8,10,18,19, sleep quality 19, relapse 16 and heroin craving 19. Also, improved treatment of physical effects of abstinence was shown by increasing body weight 9, improved liver and kidney functions 14, improved immunity 10,14 and lower adverse effects than traditional MT 8,10-13, No adverse effect was reported in 2 trials (15%) 7,14 or mentioned in 9 trials (69%) 8-11,13,15-18, only mild adverse effects was reported in 2 trials (15%) 12,19. The use of MT alone has shown effectiveness in alleviating heroin dependence in 8 trials (62%) 8,10-13, However, lower doses of usage of methadone in AT with MT than MT alone was reported in 1 trial (8%) 8 ; and improved therapeutical effects of AT with MT than MT alone was reported in 9 trials (69%) 8,10,11,13-17,19. These data reveal that AT may be used as an alternative or adjunct to the traditional MT to promote the effectiveness on treating heroin abstinence syndrome. 10

22 Table 1 Summary of RCTs on heroin detoxification by acupuncture 7-19 Trial Characteristics of (year) participants Tang Heroin addicts (N=200, 73% (2000) 7 males) Mean age, addicted period and dosage not mentioned Wu Heroin addicts (N=37, 100% (2001) 8 males) Mean age: 33.6/-6.3-y Mean addicted period: 3.0+/-1.1-y Mean dosage: 1.9+/-0.4g/d Zong Heroin addicts (N=96, 100% (2001) 9 males) Mean age: 30.5-y Mean addicted period: 29.5-m Mean dosage: 1.16g/d Song Heroin addicts (N=60, 61.7% (2002) 10 males) Mean age: 27.9+/-5.6-y Mean addicted period: 36.6+/-9.2-m Mean dosage: 1.3+/-0.4g/d Intervention Control Length of trial Outcomes measured AT (N=100) Kuai Su Wu 1 week Self-developed Yin Jie Du scale of detoxified Pian ( 快 速 patient no. 無 癮 戒 毒 片 ) (N=100) electro-at + 14-day MDT 2 weeks HAMA score, 14-day MDT (N=14) HAMD score, (N=23) methadone dosage Electro-AT Chinese MT 20 days Himmelsbach (N=20) (N=23) score, patients Electro-AT + Diazepam + body weight, Chinese MT urine morphine (N=25) (N=28) test AT + 7-day 7-day MDT 1 week HAMA score, MDT (N=30) (N=30) improved patient no., blood test of immunoglobulins Results Intervention: 90% efficacy Control: 84% efficacy. No sig difference in total efficacy between 2 groups (P>0.05) Intervention: Total methadone usage = 51.5mg ± s 31.0 mg Control: Total methadone usage = 202mg ± s 70.1mg - MT dosage on Day 1, 7 and 14 sig. lowered in treatment group (P<0.001) - Electro-AT decreased MT dosage by 75% - Symptoms of depression and anxiety in AT group sig. decreased and overall lower than control (P<0.001). - Electro-AT group sig. greater effect than control 2 days after abstinence treatment (P<0.05). - 2 electro-at groups sig. greater effect in than in other groups after 3 days (P<0.05 or P<0.01). - Sig. difference of improved patient no. between 2 groups (P<0.05). - Both groups showed effects, but AT group showed sig. greater effect than control (P<0.05). - Levels of IgG, IgA and IgM rose slightly in AT group only, no sig. difference between 2 groups (P>0.05) Comments Efficacy: AT resembles therapeutical effects of MT. Adverse effect: No adverse effect reported. Efficacy: AT might decrease dosage of MT. - AT + MT provided greater effects on improving depression and anxiety than MT alone. Efficacy: AT provided greater therapeutical effects. Remark: Heroin addicts not abstained completely in all groups during first 3 days. Efficacy: AT + MT provided greater therapeutical effects than MT alone. 11

23 Jin Heroin addicts (N=62, 79% Auricular AT 1-month 1 month Self-developed Intervention: 90.6% efficacy Efficacy: AT + MT provided (2002) 11 males) + 1-month MDT scale of improved Control: 70.0% efficacy greater therapeutical effects Mean age: 26.6-y MDT (N=30) patient no. - Sig. difference in total efficacy between 2 groups than MT alone. Mean addicted period: 5.3-y (N=32) (P<0.01) Mean dosage: 1.2g/d Zhang Heroin addicts (N=86, 91.9% Electro-AT + 10-day MDT 10 days Himmelsbach - No sig. difference in curative effect in terms of score Efficacy: AT + MT (2004) 12 males) MDT (N=43) (N=43) score, adverse reduction rate between 2 groups (P>0.05) resembles therapeutical Mean age: 27.3-y effect effects as MT alone. Mean addicted period: 8.1-y Adverse effect and side Mean dosage: 1.7g/d effect: Adverse effects alleviated by AT + MT. Side effect apparently lighter in AT+MT group. Zeng Heroin addicts (N=70, 57 AT + 10-day 10-day MDT 10 days CINA score, - Sig. difference between CINA scores before and after Efficacy: AT + MT provided (2004) 13 completed, 82.5% males) MDT (N=31) (N=26) self-developed treatment in 2 groups (P<0.01). greater therapeutical effects Mean age: 33.7+/-5.2-y scale of improved - Scores on Day 1, 2, 5-10 in AT +MT group sig. than MT alone.. Mean addicted period: patient number greater than those in control (P<0.05 or P<0.01) /-2.9-y - Grading of sweating, anxiety, pains of muscles and Mean dosage: 1.3+/-0.7g/d bones in AT+MT group showed sig. greater improvement than control (P<0.05 or P<0.01). Wen Heroin addicts (N=220, AT (N=111) Lofexidine, 10 days HAMA score, - Total HAMA scores and treatment of insomnia after 4 Efficacy: AT provided (2005) % males) (N=109) CINA score, days was sig. improved in AT group than those in greater therapeutical effects. Mean age: 33.8+/-6.9-y blood test, liver control (P<0.05, P<0.01, P<0.001). Acute heroin abstinence Mean addicted period: and kidney syndrome cured effectively 20.1+/-8.4-y function tests in 2 groups. Mean dosage: 0.8+/-0.4g/d Adverse effect: No adverse effect reported. 12

24 Rong Heroin addicts (N=94, 85.1% Scalp AT + 10-day MDT 10 days Himmelsbach - Scalp AT sig. greater effect after 10 days of treatment Efficacy: Scalp and body AT (2005) 15 males) 10-day MDT (N=30) score among 3 groups (P<0.01). + MDT provided synergistic Mean age: 31.0+/-5.9-y (N=33) - Effect of scalp AT in improving insomnia and anxiety effect and potentially better Mean addicted period: Body AT + sig. greater than that of other 2 groups (P<0.01). in reducing relapse than 7.2+/-4.0-y 10-day MDT - Effect of 2 AT groups sig. greater than that of simple MDT alone. Mean dosage: 1.0+/-0.4g/d (N=31) MDT group (P<0.01). Wang Heroin addicts (N=120, Auricular 10-day MDT 10 days Self-developed - Curative effect of AT + MT on heroin abstinence Efficacy: AT + MT provided (2005) % males) plaster + (N=60) scales of syndrome sig. greater than that of MT in control greater therapeutical effects Mean age, addicted period 10-day MDT improved patient (P<0.01). than MT alone. and dosage not mentioned (N=60) no., relapse rate - Relapse rate sig. reduced in AT+MT group (P<0.01). He Heroin addicts (N=70, 84.3% Electro-AT + MT (N=35) 1 month OWS score, Intervention: 31 complete abstinence, 1 not complete Efficacy: AT + MT provided (2005) 17 males) auricular improved patient treatment and 1 refused electro-at greater therapeutical effects Mean age: 28.2+/-6.4-y plaster + MT no. Control: 24 complete abstinence, 1 not complete than MT alone. Mean addicted period: (N=35) treatment 3.3+/-0.7-y - Sig. difference in results of 2 groups (P<0.01) Mean dosage: 0.5+/-0.3g/d - No sig. difference in OWS score in 2 groups from Day 1-5 (P>0.05) - Sig. difference in gradual decrease in OWS score between 2 groups from Day 6-16 (P<0.05 or P<0.01) Liang Heroin-withdrawal subjects Electro-AT No treatment 3 weeks HAMA scale - After treatment, HAMA scores of anxiety symptoms Efficacy: AT had great (2008) 18 (N=60, 68.3% males) (N=30) (N=30) of heroin addicts sig. improved in AT group than in effects of reducing anxiety Mean age: 33.2-y control group (P<0.01) and emotional symptoms on Mean addicted period: 5-y heroin addicts. Mean dosage not mentioned 13

25 Chan Heroin addicts (N=60, 81.7% True Sham 4 weeks PSQI scores, True electro-at: Decrease of 3.7 mg/d at week 2, Efficacy: True AT associated (2014) 19 males) electro-at electro-at self-developed 7.7mg/d at week 3, 10.0mg/d at week 4 and 8.1 mg/d with a greater improvement Mean age: 36.2-y (N=30) (N=30) scale of heroin after treatment in sleep latency. AT should Mean addicted period: 7.1-y craving score Slam electro-at: No sig. difference in daily dosage of be used as an adjunct to Mean dosage not mentioned MT from baseline to post-treatment (P>0.05) MMT in heroin abstinence - From week 2 onwards, daily dosage of MT lowered treatment due to its high by a sig. greater amount with true AT compared with efficacy. sham AT (P<0.01). Adverse effect: All adverse - True AT sig. improved PSQI scores of sleep latency at events found to be mild in follow-up (P<0.05). severity. - No sig. difference in heroin craving score (P>0.05) 14

26 Chapter 4 Discussion 4.1 Efficacy of acupuncture on treating heroin abstinence syndrome All participants in the 13 RCTs treated with AT have significantly better therapeutical effects of detoxification of heroin abstinence syndrome, in aspects of physical abstinence syndrome and psychological effects, than using MT or no treatments 7-19, indicating the use of acupuncture may be a measure for the rehabilitation of the heroin and opioid abusers with potentially lower health concerns. The discussion below focuses on the safety of methadone medications, advantages of using acupuncture over traditional MT and psychotherapy, the mechanism of acupuncture for treating heroin abstinence syndrome, and suggestions for ND, HA, NGOs and other public health institutes Health effects of methadone on human body Traditional treatment of heroin abstinence syndrome mainly uses methadone in MMT or MDT, which probably results in severe health impacts on the patients. From a study in USA, from 1997 to 2001, there was a 4-time increase in the use of methadone for treatment purpose, meanwhile the mortality rose from 0.16 to 0.98 per 100, It was identified that the use of methadone was the primary cause of the increased number of deaths 24. The action of methadone on the human body may explain the side effects of methadone medications. Methadone is metabolised by half slowly in 15 to 60 hours inside human body, having a highly fat-soluble nature 25. So methadone can dissolve in the tissues, making it longer-lasting than other opioid drugs by its continuous stimulation to the nervous system 25. Hence, the conventional MMT and MDT programmes should be revised by the government due the rising health 15

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