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Fears and Dependence

From a Traditional to a Contemporary Approach

Gustavo Quaresma, MD; SPMAGustavo Quaresma, MD; SPMA

5th International Medical Acupuncture Congress

Barcelona, November 2011

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Layout of the Presentation

1- Introduction

2- Fears and Dependency in Traditional Acupuncture

3- Fears and Dependency in Contemporary Science and Acupuncture

4- Treating Addiction with Acupuncture (State-of-the-Art)

5- New Ideas for Treating Addiction with Acupuncture5- New Ideas for Treating Addiction with Acupuncture

6- Conclusions

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Introduction

“These research programs do not confirm the hypothesis that needling at

specific points is essential to achieve satisfactory clinical effects…”

Modellvorhaben Akupunktur – a summary of the ARTC, ARC and GERAC Trials

Mike Cummings; Acupunct in Med March 2009

“Local effects can be obtained needling almost anywhere, but there are also

certain places throughout the body …the classical acupuncture points.”

An Introduction to Western Medical Acupuncture; pg. 21

Adrian White; Mike Cummings; Jacqueline Filshie

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Fear and Dependency in Traditional

Acupuncture

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Five elements

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The Five Elements/Characteristics

• Season, Cardinal Points, Climate, and Planets

• Taste, Smell, Colour, Sounds

• Phases of Development

• Organs (Zang), Viscera (Fu), Emotions

Sense Organs, Tissues, Excretions• Sense Organs, Tissues, Excretions

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Organs and Psychism

• Psychism (ideas, thoughts, feelings, emotions…) results from the

functional activity of every organ .

• Each organ’s activity contributes towards the Mental, Emotional and

Spiritual Universe

• By treating the somatic, we are simultaneously treating the emotional side

(with some specificities…)(with some specificities…)

• Liv 3 Example (anger and headaches)

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Water Movement

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Water Movement/General Aspects

• Kidney (and Suprarenals) and Bladder

• Bones, Teeth, Hair, Sexuality, Salty, Black

• Cold, Winter, Water, Death, Groaning

• Growth and Development Rules

Feet, Knees, Lombar Region, Ears• Feet, Knees, Lombar Region, Ears

• Genitourinary System and Suprarenals

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Water/Psychism

• Carrying out Intentions (Will and ability to carry them out)

• Authority, leadership, ability to reach goals and realize one’s potential

• Associated to responsibility, self-esteem, confidence in oneself, autonomy

and independence

• (Negative) Emotion is Fear (and anguish), not being able to carry out the

tasks for which we are responsibletasks for which we are responsible

• Associated to physical pleasure /desire, fighting courage, and to Death

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Water/Addictions

– Dependency, No Will– Dependency, No Will

– Loss of ability to carry out decisions

– Heredity and Sexual problems

– Organs and Tissues (Teeth, Bones, Hair)

– Defense against External Agents

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Fears and Dependency in Contemporary

Acupuncture and Science

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General Physiology Acupuncture

“Acupuncture needling has local effects through local antidromic axon reflexes, releasing neuropeptides such as calcitonin gene related peptide and reflexes, releasing neuropeptides such as calcitonin gene related peptide and increasing local blood flow…. In the spinal cord and brain, there is well established evidence that acupuncture causes the release of opioid peptides and serotonin. The clinical effects on musculoskeletal pain are best explained by inhibition of the nociceptive pathways at the dorsal horn by activation of the descending inhibitory pathways and possibly by…effects on miofascialtrigger points. There are clearly other actions of acupuncture on the central nervous system…good evidence of effects on various brain centres involved in pain control, notably the limbic structures, including the insula”

White, A., Western Medical Acup…: a definition. Acupunct Med, 2009. Vol. 27(nº1): p.33-36. n musculoskeletal pain are be

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Acupuncture/Central Effect

“The Limbic structures are implicated in the reward system and play a role in

most disease and illness responses including chronic pain and depression,

regulating mood and neuromodulatory responses (sensory, autonomic, regulating mood and neuromodulatory responses (sensory, autonomic,

endocrine…). The pleasurable and neuromodulatory aspects of acupuncture,

as well “placebo needling” may partly be explained by the activation and

deactivation of limbic structures including hippocampus, amygdale and their

connections with the hypothalamus.”

“…long term pain-alleviating effects have been attributed to activation of

pain inhibiting systems in cortical and subcortical pathways. When pain inhibiting systems in cortical and subcortical pathways. When

considering long term effects, the cortico-cerebellar systems need to be taken

into account. “

Lundberg T. and col.; Acupuncture- Self-appraisal and reward system

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Acupuncture/Central Effect

“… Stimulation of the ear induced a significant increase in the “… Stimulation of the ear induced a significant increase in the

parasympathetic activity during the stimulation period of 25 min and

during the post-stimulation period of 60 min. No significant changes

were observed in…the sympathetic activity.”

Haker E. and col.; Effect of sensory stimulation (acupuncture) on sympathetic and

parasympathetic activities in healthy subjects; Journal of Autonomic Nervous System; 79 (2000); parasympathetic activities in healthy subjects; Journal of Autonomic Nervous System; 79 (2000);

52-59;

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Acupuncture/Extra Segment Effect

The Structures responsible for working at CNS level and later activatingthe Descending Inhibitory Systems are the :

– Hypothalamus (Arcuate Nucleos) – Hypothalamus (Arcuate Nucleos)

– Brainstem (PAG , Parabrachial Nucleus)

– Pons (NGC and NMR)

There are two types of action on the Descending Inhibitory Sytems:

Noradrenergic - NCG (Giant Cell Nucleus)

Serotoninergic- NMR (Nucleus Raphe Magnus)

The Serotonin and Enkephalins/Endorphins descending Inhibitory pathsseem to respond better to low electric frequencies (1 to 20 Hz) and theNoradrenaline and Dinorphin respond better to high frequencies (80 to 200 Hz).

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Fears and Dependency in Contemporary

Acupuncture and Science

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Acupuncture, Neurotransmitters

and Brain Mapping

“Acupuncture first gained credibility in the scientific community when it was shown to

release opioid peptides…

- B-endorphin: midbrain and PAG; µµ and δδ; EA 2-4 Hz

- Enkephalin: Dorsal Horn and S. Cord; µµ and δδ ; 2-4-Hz

- Dynorphin: Brainstem and spine; κκ; 50-100 Hz

- Endomorphin: General; µµ ; 2-4-Hz”

An Introduction to Western Medical Acupuncture

“…acupuncture induces signal decreases (fRMI)in a coordinated network of limbic regions…amygdale, hippocampus, cingulate and cerebellar vermis…”regions…amygdale, hippocampus, cingulate and cerebellar vermis…”

Napadow V. and col; Conference Report: Neurobiological Correlates of Acupuncture, Nov 2005; The Journal of Alternative and Compl. Medicine;

Vol. 12; Nº 9; 2006; p 931-935

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Acupuncture and Physiology of Addiction

“On the other hand, one behavioral study has indicated that high-frequency “On the other hand, one behavioral study has indicated that high-frequency

electroacupuncture suppressed the naloxone induced morphine withdrawal

syndrome and this effect was reversed by pretreatment with dynorphin A

antibody or k-receptor antagonist.”

Chae Ha Yang and col; A possible mechanism underlying the effectiveness of

Acupuncture in the treatment of drug addiction; eCAM 2008;5(3)257-266

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Acupuncture and Physiology of Addiction

“… low-frequency electroacupuncture can activate enkephalinergic and “… low-frequency electroacupuncture can activate enkephalinergic and

b-endorphinergic neurons in the nucleus arcuatus of the hypothalamus.

Accordingly, it seems reasonable to propose that low–frequency

electroacupuncture may help to enhance the release of dopamine in the

nucleus accumbens via δδ-opioid receptors in the nucleus accumbens as

well as m-receptors in the VTA.”

Chae Ha Yang and col; A possible mechanism underlying the effectiveness of Chae Ha Yang and col; A possible mechanism underlying the effectiveness of

Acupuncture in the treatment of drug addiction; eCAM 2008;5(3)257-266

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Treating Addiction with Acupuncture

(State-of-the-Art)

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Points and Effectiveness

“Acupuncture for the treatment of cocaine addiction: a randomized controlled trial; Margolin A ; JAMA 2002;

“NADA Auricular protocol, Needles were inserted into the auricular bilaterally at 4 points…“NADA Auricular protocol, Needles were inserted into the auricular bilaterally at 4 points…

…Auricular Needle insertion Control Condition…into the helix of the auricles bilaterally at 3 regions not commonly used for addiction treatment…

…acupuncture was not more effective than a needle insertion or relaxation control in reducing cocaine use…”

“Acupuncture for the treatment of cocaine addiction. Investigation of a needle puncture control”; Avants SK et al; J Subst Abuse Treat 1995;

“…for the purpose of identifying an appropriate needle puncture control…Cocaine use decreased significantly for patients in both needle puncture groups…in control sites within 2.3 mm of the four active sites…We found no statistically significant control sites within 2.3 mm of the four active sites…We found no statistically significant difference between the active and control …very large sample sizes would be required to detect treatment differences … Alternative controls are suggested…”

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Points and Effectiveness

“A programme for the treatment of drug-addicted persons; Smith M O, Khan

I;

“…The programme receives, on a daily bases, 200 drug addicted

persons…The best results have been obtained by treating patients in an open

group setting using acupuncture points in the external ear with needles

without electrical stimulation ”

“…The mechanism of action of acupuncture has not been fully

understood…autonomic nervous system, various neurotransmitters, and

elements in the pituitary-subcortical axis…relief of withdrawal symptoms and

craving, general relaxation and homeostasis… ”craving, general relaxation and homeostasis… ”

“…following points are used: sympathetic, , shenmen, kidney, liver,

lung…”

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Reflection on Effectiveness

• Reflection:• Reflection:

- Randomized Control Trials and Systematic Reviews provided weak outcomes

- Experience of Patients and Professionals provided interesting results

• Possibilities:

- Acupuncture not very effective when dealing with Addictions

- EBM criterium unsuitable for evolution of Acupuncture

- Sham Acupuncture concept incorrect- Sham Acupuncture concept incorrect

- Incorrect therapeutic choices (same points-different patients)

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New ideas in Treating Addiction

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General Principles

• Each Patient must be individually examined so as to determine his/her

Physiopathological imbalance

• This imbalance can be determined within the Western Paradigm and also

within the Traditional Paradigm to try to maximize results.

• Within the Oriental Paradigm one must take into account the 5 Elements

approach to which different therapeutic possibilities are associated.

• Within the Western Paradigm, we may also consider the ANS,

Neurotransmitters, the Organs, and areas of the Brain.

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General Principles/ANS

- Stimulating the SNS

• High intensity; High frequencies (80 to 100 HZ)• High intensity; High frequencies (80 to 100 HZ)

• Muscular Puncture ; Para vertebral Muscles T1 to L2

• Triangular Fossa and Tragus (trigeminal)

• Members in the T1 to L2 segments

• Members in the areas innervated by the: peronial, tibial, median, cubital

- Stimulating the PNS

• Low intensity; Low frequencies (2 to 4 HZ)• Low intensity; Low frequencies (2 to 4 HZ)

• Cutaneous Puncture

• Para vertebral Muscles S1-S4

• Conch (Vago) and Anti-tragus (Glossopharingeal)

• Members in the sacrococcygeal segments

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General Principles/Organs

• Define Organs with pathology (and their Autonomic imbalance?)

- Organic symptoms

- Somatization Disorders

- Neuropeptides and Emotions

. Choosing Points and techniques according to the imbalance

- For the spinal of the segment in question (SNS or PNS)

- Points in Members according to the chosen segments- Points in Members according to the chosen segments

- Choice of auricular Points according to ANS (and traditional map?)

- Check frequencies and intensity

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General Principles/Neurotransmitters and Brain

Mapping

• Neurotransmitters Approach

- Diagnose according to Neurotransmitters?

- Choose suitable frequency and intensity

- Consider interaction with the SNS and PNS

- Pay attention to the 2 descending inhibitory systems

• Brain Mapping Approach

- Define areas of brain in question…

- Sensorial cortex (associated to locals of puncture?)

- Cerebellum; Prefrontal cortex; Hypothalamus

- Limbic system (Deactivation)

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General Principles/Addiction

“To summarize the research described earlier, low- frequency electro-

acupuncture appears to play a critical role in attenuating the motivational aspects

of drug withdrawal, while high-frequency electro-acupuncture may be most of drug withdrawal, while high-frequency electro-acupuncture may be most

effective in reducing withdrawal symptoms.

Chae Ha Yang and col; A possible mechanism underlying the effectiveness of Acupuncture in the

treatment of drug addiction; eCAM 2008;5(3)257-266

“…high frequency stimulation is best for reducing the physical dependence…low

frequency for psychic dependence…advantages of using transcutaneous

stimulation…HANS Protocol introduced by the Neurosciences Research Institute of

Pekin university…”.Pekin university…”.

“Acupuncture for the treatment of drug addiction; Cai-Lian C et al; Neurochem Res (2008);

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Conclusion

Based on the hypotheses here mentioned, which have to be

verified, to increase the efficiency of Acupuncture in Mental Health...

… the choice of the Type of Acupuncture (points of stimulation,

depth of the puncture and structures reached, frequency of sessions,

electrical frequency and intensity of the stimulus…) should be related more so

to the Disease’s Physiopathology than to existing Clinical history.

Also considering that the Hypotheses presented are valid, it is worthAlso considering that the Hypotheses presented are valid, it is worth

checking if the reflections in question could successfully be applied to other

Mental Health Pathologies.

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Conclusion

– Compare efficiency of Acupuncture with Usual Care

– Use specific points for different Patients with same diagnostic

– Clinical and Basic Investigation at the same time

“We recommend that acupuncture treatements should be studied (1) top-down as

multi-component whole-system interventions and (2) bottom-up …individual multi-component whole-system interventions and (2) bottom-up …individual

treatment components interact…into clinical and physiological outcomes…”

“Paradoxes in Acupuncture Research: Strategies for moving forward”

Society of Acupuncture Research- Symposium to 2007

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Suggestions accepted/ gjquaresma@gmail.com

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Thank you!

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