AP in Detoxification / Withdrawal
FROM DRUGS & ALCOHOL (3/3)
Smith_MO7 (1986) AP Treatment for Alcoholism.
The Lincoln AP Program is a successful revenue-producing unit which is fully integrated within the hospital system of New York City. It has served as a model for the programs in Brooklyn and Minneapolis described below as well as others in the USA and abroad. The experience of these other programs indicated that our approach can be taught and implemented successfully in a wide range of programs.
AP training program
In the past decade we have trained over 150 people to perform detox AP who were previously counsellors, nurses, social workers, psychologists and physicians in conventional drug and alcohol treatment settings. While adapted to Western attitudes and conditions, the NADA method derives directly from TCM theory of detoxification. Some of these AP detox trainees have continued their study of TCM to become experts in general AP therapy. Other trainees are working in many public and private addiction treatment settings across the USA and in Europe.
National AP Detox Assoc (NADA) was formed to coordinate training and certification of AP Detox Specialists, designated "ADS". NADA was formed so that the field of AP and chemical dependency can be merged properly and that the critical importance of psychosocial rehabilitation not be lost in the enthusiasm for this new modality. As consultants for NADA, we found that many alcoholism staff members can readily learn the additional technique of ear AP detoxification and integrate this modality into their existing protocol of long term rehabilitation. To further improve understanding, NADA distributes an extensive range of approved educational materials, including literature, audiotapes and videotapes.
The following summary of the NADA training program with the Crow tribe and Sioux Nation in the USA has international significance because the Crow and Sioux are very isolated from the mainstream of Western culture and have economic and social problems that are typical of underdeveloped nations.
Native American AP detoxification
NADA has given 2 very successful training programs for Native American alcoholism programs located in the Crow and Sioux reservations. Alcohol abuse among Native Americans is extremely common. All parties agree that existing treatment efforts are failing to make any headway in coping with this genocidal threat. Extremely few detoxification beds are available for Natives who live on the reservation. In spite of the high unemployment, there is an effective social support system that derives from the traditional tribal culture and the dedication of younger educated Natives who remain on the reservations. The most dangerous problem is the lack of detoxification facilities.
NADA's goals were: 1. to show the usefulness of AP detox in the Native American setting; 2. to train Native alcoholism staff in the techniques, uses, and limitations of AP detox; 3. to supervise the development of an AP component in the local treatment programs.
We found a very similar pattern of success in each program. Our training staff gave >150 AP treatments at each site. These treatments laid the basis of trust between the tribal leadership and ourselves. They observed that AP was a potential answer to urgent public health needs on the reservation. Most regular Native alcoholism staff members were able to learn ear AP for detoxification well enough to provide regular treatment and receive NADA certification. 18 native clinicians from 4 different reservations were certified. During the workshop, needles were sterilized at the adjacent Govt hospital. A complete written protocol was set up for the whole treatment process and it was followed carefully and completely by the Native staff.
The programs we visited were demoralized, low census facilities with a high rate of staff burn-out. The Native staff consistently showed concern and involvement with their patients, but they were seriously handicapped by the poor response of the clients to conventional treatment. In each program the census jumped 5-10 fold during the first wk of training. 2 mo later, the Crow Detox Program continues to give 40 AP treatments/wk, a 500% increase in daily treatment volume. Medication for in-patients (e.g. chloral hydrate) was totally discontinued after the 4th day of training at Crow Agency. Many previously uncooperative clients at the Pine Ridge Sioux Reservation became model patients after 1-2 d of AP. They gained a new found calmness, respect for themselves, and thus a growing interest in the counselling components of the program.
Typically disgruntled and toxic alcoholics from the Sioux jail were referred for AP as part of their rehabilitation. The motivation in this group became so positive that they built a sweat lodge facility for the reservation while still serving their brief sentences. Sweat lodges are used by the Indian community as a means of body cleansing and meditation. Many Natives remarked to us that the TCM approach represented by AP is very similar to their own health traditions. The Sioux said that AP was "takus kanskah" in the Lakota language. The translation of this term, "something holy moving" is very similar to the TCM concept of Qi (vital energy) which is the TCM explanation of the AP effect. Both programs were so visibly successful that long graphic stories have appeared in the major dailies of Montana and South Dakota, as well as the Lakota Times and KILI, the Pine Ridge station. The regional board of Indian alcoholism and the Indian Health Service at Aberdeen, South Dakota have shown interest in using AP detoxification in other reservation programs and a planned regional treatment centre.
Clinical examples
AP detoxification clients at Lincoln include abusers of alcohol, heroin, cocaine, methadone, sedatives, stimulants and hallucinogens alone, or in combination. Some of these patients have a primary psychiatric diagnosis, and others have psychotic toxicity resulting from acute and chronic drug use. The following examples illustrate the challenge of treatment that we have accepted.
Difficult intakes
We have many intensely disturbed people who come to our building for help. One 42-yr-old man, AB, had pages of the bible taped to his chest, and had a large knife extending out of his pocket. He was currently sober but had been referred by a local hospital for alcoholism treatment. As we hesitantly spoke to AB in the AP area, he turned his head around and asked, "can I get some of this? " We were surprised at his interest but gave Ear-AP treatment. AB slept for a while and then was quite willing to be accompanied to a hospital emergency room for admission.
Support for other therapy
RR, referred by a family court social worker, had a long record of alcoholism and child abuse. She had been attending therapy sessions weekly for the past yr with no change in her behaviour.
Smith_MO8 (1986) AP Treatment for Alcoholism. RR was labelled a poorly motivated patient. After 1 wk of AP, her children and neighbours came to the clinic and reported a very agreeable change in her behaviour. RR said this time the impulse hadn't been as strong and she "had been able to remember what her therapist had told her". This patient had not been poorly motivated; she had attended weekly sessions even though there had been no progress. She did not have a poor memory; on the contrary she had been distracted from remembering effective suggestions by an impulse disorder and alcohol abuse. RR only took AP for 23 wk, nevertheless the treatment helped her use the therapy sessions more effectively so that the past year's effort was not wasted. The court agency reports RR continued therapy and no longer shows a tendency towards child abuse.
Management of violence between clinic patients
Usually the possibility of violence between patients would paralyse the treatment process. AP has helped us treat clients within their existing environment of social turmoil. It is much too expensive and impractical to institutionalize every troubled violent person in a city such as New York. As a society we must develop community-based methods of coping with widespread substance abuse and violence.
Herbal detoxification
Herbal treatment has been used for alcohol detoxification and nervous relaxation for millennia in may parts of the world. The herb mixture that we rely on contains chamomile, catnip, peppermint, skullcap, hops and yarrow. The herbal mix is prepared exactly as tea is prepared, using honey instead of sugar. The mixture is less expensive than coffee. Our Lincoln "sleep-mix" can be used for relaxation and insomnia in stable persons. The same mixture is effective for alcohol detoxification if taken every hour. These herbs are not habit forming and do not have any risk of overdose or misuse. Our "herbal formulary"included in the NADA-approved literature, audiotapes and videotapes explains the nature and effects of these ingredients more completely.
Staff attitudes and strengths
Clinical staff who work with AP detoxification patients understand the special opportunities and requirements that we have described in this paper. They can foster autonomy and work in a calm atmosphere. Flexibility and tolerance of recently relapsing clients. Skills involving touching and other non-verbal support are also valuable in this setting. Staff members who use relatively authoritarian, judgmental or guilt-producing techniques do not adjust well to the necessarily gentle and permissive atmosphere of an AP detoxification setting. In the large group setting we do not emphasize authority symbols such as desks and signs. The patients can watch the acupuncturists and counsellors work so that they can feel like they are participating in the treatment procedure.
Many substance abuse clients are obsessed with guilt and self-deprecation. They must try to learn not to link every withdrawal symptom and craving with psychological issues. Even though substance use disorder is an overall psychosocial matter, it is not helpful to psychologize every step of the detoxification process. When a detoxing client starts to cry, teach them not to ask or worry about the "cause" of the tears. Clients should expect to face the psychosocial problems gradually as they gain strength and after the basic cleansing and balancing process.
Usually, our patients are unable to tolerate intense one-to-one relationships. We disarm them by coping with their turmoil in a non-attached, gentle manner. This form of interaction protects the patient from their own feeling of inadequacy and allows that the effect of AP is not comparable to the sedative effects of drugs. AP helps the body develop a healthy neutral state similar to that of meditation or yoga. This condition leads to healing and growth, not merely the control of symptoms. In TCM the lack of calm inner tone in a person is described as a Syndrome of Empty-Fire (Xu-huo), because the Heat of aggressiveness burns out of control when the calm inner tone is lost.
It is easy to be confused by the Empty-Fire (Xu-huo) that many alcoholics present and to conclude that the main goal should be sedation of Fire-Excess (Fire-Shi). The addict himself takes this approach in the extreme by use of sedatives. The hostile, paranoid, hustling climate of our inner city communities exemplifies a Qi-Xu Syndrome with Empty-Fire burning out of control.
Our patients seek greater power and control over their lives. The Empty-Fire Syndrome represents the illusion of power. An illusion that leads to more desperate chemical use and senseless violence. AP provides an effective treatment for these Empty-Fire Syndromes. The patient is empowered, but in a soft and easy manner.
Let me conclude by describing the cheerful and cooperative atmosphere that AP detoxification engenders. We are a crowded walk-in clinic in the South Bronx, one of the poorest sections of the city. Our former methadone component was always filled with argumentative and hyperactive behaviour. The AP component had always had a calm and cooperative atmosphere even though it was staffed by precisely the same people in the same confines. As well as clients for detox, we have many clients who receive AP treatment in the same settings for general medical conditions. Visitors to our clinic see middle-aged housewives, young professional people and working class people, all sitting side by side together with many substance abusers in a harmonious atmosphere. Social bonds become re-established because the treatment modality does not further isolate and stigmatize our clients.
Smith_MO9 (1985) Chinese Theory of Detoxification. Adapted from WWW, NADA Home Page. Michael O Smith MD DAc, Lahary Pittman, CAC, CA, Ana Oliveira, MA, CA.
From 1974-1985, out of necessity and by choice, the AP staff of Lincoln hospital has tested many AP methods for chemical dependency. In the past 4 yr, our basic protocol has given consistently impressive results with many different practitioners and a wide range of settings. Thus, we confidently add this theoretical discussion to the body of AP learning.
Implicated in the disorders of alcoholism and drug addiction are a wide range of substances (e.g. alcohol, heroin, methadone, barbiturates, valium, PCP, cocaine, etc). Nevertheless the similarity of AP points that are effective for these apparently different substances indicates that the critical Qi disturbance is similar in most, if not all, cases. Intense and frequent abuse of chemical substances damages the Jing-Essence (sexual Qi). In turn, KI is damaged because it is the organ (Zang) that stores Jing. Usually Yin-Xu exists, so we see many Empty-Fire (Xu-huo) symptoms. Yang-Xu symptoms also are present.
The symptoms of prolonged withdrawal may last up to 6-12 mo and usually take a psychological character. Periodic agitation, fear, lethargy, and poor response to stress are typical. Insomnia, bone pain, sluggish digestion, poor sexual function may be present also. Usually the patients consider these prolonged symptoms as a permanent result of their past activities. They are quite amazed that fresh clear youthful life is still possible.
We use ear AP with great success in treating these problems, both on a crisis and long term rehabilitation basis. The ear is the sense organ most related to KI. We extend this relationship further by saying that points on the external ear relate especially to KI function. The external ear is the part of the body that is most unchanged since birth. It is passive in function and is shaped like a fetus or a KI. In our experience, in contrast to treatments for knee and shoulder pain, Ear-AP treatment is more effective for KI-related locations (foot pain, sciatica). In our protocol the main needling locations are KI-related points and Ear Shenmen (a point that promotes lower abdominal circulation). The added points, LU, LV, etc, are chosen and located by sensitivity reactions and are related to secondary symptoms.
Jing-essence and KI are Yin in nature. When they have been damaged the recovery process is slow and undulating in intensity. Using frequent repetitions of KI-related Ear-AP is very effective in treating even debilitated addicts and alcoholics. Significantly, even those patients with severe paranoia respond well to this protocol. Paranoia involves fear (KI-related emotion) and a hollow aggressive ego structure that certainly is an Empty-Fire (Xu-huo) phenomenon. This often afflicts patients who are perceived by most health care settings as presenting a risk of violence. The routine ear protocol is more effective with more desperate and antagonistic patients, as one might expect. These patients are precisely the ones who have suffered more Jing damage and exhibit more prominent Empty-Fire symptoms. Also, many socially functioning Empty-Fire patients who may or may not be abusers, benefit greatly from these treatments. On the other hand, patients with relatively moderate chemical dependency or who have completed most of their recovery do not respond as well to the Ear-KI protocol and require body AP planned according to the conventional principles of TCM.
This distinction between treatment protocols for moderate and severe abusers is critical. The severe abusers are the group of patients most in need of better health care and most resistant to virtually all forms of intervention. By purifying the Jing-Essence and strengthening KI, we rehabilitate these Xu (Weak) patients so that they can return to function on the every day expected level of Jing function. Our clients need Ear-KI treatments before they can respond to other AP, psychological and spiritual treatment. We cannot overestimate the critical importance of using Ear-KI treatment as the primary form of AP for chemical dependency. Its use opens a world of relief for millions of chemically dependent people and their families.
Our AP treatment is mainly to tonify Yin. Many background aspects of our treatment setting contribute to Yin-tonification. Treating more patients simultaneously in a large sitting room clearly enhances the results. Patients certainly prefer to come when the room is crowded and they are usually more quiet when the room is more crowded. Shared experience is a Yin approach; whereas focused individual therapy is Yang. We take steps to minimize direct, intrusive interchanges whether in the form of clinic rules or verbal therapy. We share the patient care rather than focusing one acupuncturist on a particular patient each day. Before we became aware of it, the patients created a meditation-like atmosphere in the treatment room. This atmosphere is attractive to abusers of stimulants as well as patient's Yin (private, silent) development. American society as a whole is toxic and Yin Xu. Our Yin-tonifying setting is uniquely supportive and popular in providing all types of AP and other health care.
Stellato_Kabat-D (199.) AP detoxification [letter]. Soc-Work. 1994 Sep; 39(5):623-624.
ter_Riet_G; Kleijnen J; Knipschild P (1990) A meta-analysis of studies into the effect of AP on addiction. Br J Gen Pract Sep 40(338):379-382. Dept of Epidemiol and Health Care Research, Univ of Limburg, The Netherlands. A literature search revealed 22 controlled clinical studies on the efficacy of AP in 3 fields of addiction: cigarette smoking (15), heroin (5), and alcohol (2). These studies were reviewed using a list of 18 predefined criteria of good methodology. A maximum of 100 points for study design could be earned, divided over 4 categories: comparability of prognosis; adequate intervention; adequate effect measurement; and good data presentation. The study design was generally poor. No study earned >75 points and 12 studies (55%) earned <50 points. For smoking cessation, the number of studies with negative outcomes exceeded by far the number with positive outcomes. Taking the quality of the studies into account this negative picture becomes even stronger. For heroin and alcohol addiction controlled clinical research is both scarce and of low quality. Claims that AP is efficacious as a therapy for these addictions are thus not supported by results from sound clinical research.
Washburn_AM; Fullilove RE; Fullilove MT; Keenan PA; McGee B; Morris KA; Sorensen JL; Clark WW (1993) AP heroin detoxification: a single-blind clinical trial. J Subst Abuse Treat Jul-Aug 10(4):345-351. Univ of California, San Francisco. The increasing prevalence of HIV infection among injection drug users mandates the development of innovative treatments. While extensive clinical experience suggests that AP detoxification is both acceptable and safe to those in withdrawal, little research has been done to assess its therapeutic efficacy. In this first controlled study of AP heroin detoxification, 100 addicts were assigned randomly, in a single-blind design, to 2 groups: 1=standard Ear-AP treatment used for addiction; 2=Sham-AP treatment that used points that were geographically close to the standard points. Attrition was high for both groups, but subjects assigned to the standard treatment attended the AP clinic more days and stayed in treatment longer than those assigned to the sham condition. Additionally, attendance varied inversely with self-reports of frequency of drug use, suggesting that those with lighter habits found the treatment modality more helpful. Limitations of the study are discussed.
Worner_TM; Zeller B; Schwarz H; Zwas F; Lyon D (1992) AP fails to improve treatment outcome in alcoholics. Drug Alcohol Depend Jun 30(2):169-173. Alcoholism Services, Long Island Coll Hospital, Brooklyn, NY 10201. 56 alcoholics (49 male, 7 female) of lower socioeconomic class attending an outpatient treatment program in Brooklyn, New York were prospectively randomized to one of 3 treatment group: point-specific AP, sham transdermal stimulation or standard care (control). One third of the subjects reported a history of drug use in addition to alcohol. There were no significant differences in attendance at Alcoholics Anonymous meetings, number of outpatients sessions attended, number of wk in either the study or in the outpatient program, number of persons completing treatment or in the number of relapses. In this small racially mixed sample of urban outpatient alcoholics, fixed point-specific standardized AP did not improve outcome. We caution against the routine use of this treatment until more randomized controlled trials show a beneficial effect.