Auricular Therapy ResourcesCara Michele Nether, M.Ac., L.Ac., NADA RT 1014 Dulaney Valley Rd Towson, MD 21204 410.823.0151 ADS Training Participant Survey OETAS December 15‐17, 2008 This information will help us facilitate a smooth transition from this training into the practical portion of the training and ultimately into ADS certification for those who complete all the requirements. Thank you for taking a moment to complete it! Name: _______________________________________ Organization Name (if any): _______________________________________________ Do you plan to complete the entire ADS training program (these three days of didactic training, submitting homework assignments and completing 40 hours of practical training) and to become certified as an ADS in the state of Maryland? YES____ NO____ If NO, you do not need to complete the rest of this form. Thank you! If YES: Does your organization already have an established Acudetox program? YES____ NO____ What is the name and contact information for the acupuncturist supervising this program? Name: _________________________ E‐mail: _________________________ Phone: ___________ If not, is your organization planning to begin an Acudetox program? YES____ NO____ YES____ NO____ Have they been in touch with Cara Michele about getting started? If you are not currently associated with an organization, do you know of an acudetox program where you plan to complete your practical hours? YES____ NO____ If so, what is the name of the organization: __________________________________ THANK YOU! Cara Michele Nether, founder of Auricular Therapy Resources, is a licensed acupuncturist and a registered trainer with the National Acupuncture Detoxification Association (NADA). Cara Michele provides training to acupuncturists and eligible non‐acupuncturists in the use of the NADA Five Needle Protocol, an ear acupuncture protocol. Page 1 Auricular Therapy Resources Cara Michele Nether, M.Ac., L.Ac., NADA RT 1014 Dulaney Valley Rd Towson, MD 21204 410.823.0151 Acupuncture Detoxification Specialist Training: December 15‐17, 2008 OETAS, Alcohol and Drug Abuse Administration 55 Wade Ave, Catonsville, MD 21228 Faculty: Cara Michele Nether,M.Ac.,L.Ac.,NADA RT 443‐527‐8425 Kathy Crosland, M.Ac.,L.Ac., 410‐750‐2793 Purpose: • Objectives: To successfully pass this course, the student shall: • learn to identify and use morphology of the ear in order to find and needle the 5 auricular points used in acupuncture detoxification as determined by the NADA protocol; • gain a practical understanding of the concepts of yin deficiency and empty fire as they apply to substance abuse and recovery; • learn and be able to apply clean needle technique (CNT) and blood borne pathogen (BBP) procedures specific to community health work; • develop an understanding of the role of acupuncture in relation to addiction recovery. • learn the uses of the Sleep Mix Tea and seeds/beads in the NADA treatment style Outcomes: At the end of this training, the student will: • be able to demonstrate compassion, sensitivity and respect for clients; • be able to accurately locate and safely needle the five auricular acupuncture points of the NADA 5‐needle Acudetox protocol; • be able to demonstrate and apply blood borne pathogens procedures and clean needle technique as they apply to community health work; • be able to modify treatment appropriately when needed and to respond to needle shock should it occur;. • be able to demonstrate understanding and compliance with the scope of practice as defined by Maryland state law and NADA ethical principals. To prepare well qualified practitioners who can demonstrate the skill of the NADA 5‐needle protocol and the NADA treatment style.
[email protected] [email protected] Page 1 Auricular Therapy Resources Cara Michele Nether, M.Ac., L.Ac., NADA RT Prerequisites: • Syllabus: 1014 Dulaney Valley Rd Towson, MD 21204 410.823.0151 To participate in this training you must be a licensed individual who works or intends to work in the addictions treatment field. The following topics will be covered during this three‐day intensive training: • Auricular landmarks and morphology; • The NADA 5‐needle Acudetox protocol: point locations, theory and functions and NADA style treatment; • Blood borne pathogens procedures and clean needle technique specific to community acupuncture work; • Needling technique; • Chinese medicine view of addictions and recovery; • Psycho‐social characteristics of the NADA protocol; Method of presentation: This course is presented as a combination of lectures, demonstrations, video and experiential learning. Attendance policy: It is very important that students attend class for the entire 20 hours of class time. A roster will be passed around every day for students to sign. Assignments: • • • Students are to review the manual and point location in the evening and practice needling on fruit and inanimate objects. There will be a short quiz in the morning of the second day. Each student is to hold an acupuncture needle in his or her hand for 4 hours at least two different days after the training and write about the experience. Turn in a 1 page summary emailed to me at
[email protected] no later than January 17, 2009. Write a page about your training experience. Include how your involvement with the 5‐needle protocol and the NADA style of treatment will/has changed how you work with your clients and how learning this work has benefited you. Turn in a 1‐2 page summary emailed to me at
[email protected] no later than January 17, 2009. • Page 2 Auricular Therapy Resources Cara Michele Nether, M.Ac., L.Ac., NADA RT Evaluation: 1014 Dulaney Valley Rd Towson, MD 21204 410.823.0151 Successful completion of this course requires full attendance during the 3 days, successfully passing the short‐quiz, demonstrating sufficient skill and proficiency at needling the 5 NADA points to safely treat clients, and submitting homework assignments by the due date. The final determination of skill and proficiency is at the sole discretion of the NADA trainer. Reading list: Recommended: Brumbaugh, A. (1994). Transformation and recovery: a guide for the design and development of acupuncture‐based chemical dependency treatment programs. 1st ed. Santa Barbara, CA: Stillpoint Press. Recommended: Mitchell, E. (1995). Fighting drug abuse with acupuncture: the treatment that works. 1st ed. Berkeley, CA: Pacific View Press. Materials: All the materials needed for the completion of this course will be provided. Additional course specific information: This is a very intense and rewarding 3 day course. You will be needling your classmates and they will be needling you. Some students experience emotional upsets and suppressed and repressed emotions often arise during the repeated needling of the NADA points. This is not uncommon and is OK, allow these feeling and emotions to arise and be processed. Your ears may be sore and you may not want to be needled any more. If this occurs please talk with the instructors. We need everyone’s full participation so that everyone gets the chance to practice needling prior to treating clients. Clients will also not want their ears needled at times and by working through it yourself you have a place of power from which to operate. Lastly, this treatment will lower you tolerance to alcohol and street drugs. If you find you must indulge, please do so cautiously. Page 3 Third Edition Acupuncture Detoxification Specialist Training Manual A handbook for individuals training in the National Acupuncture Detoxification Association’s Five-needle Acudetox Protocol. 2008 National Acupuncture Detoxification Association National Acupuncture Detoxification Association P.O. Box 1927 Vancouver, WA 98668-1927 USA Toll Free Phone: (888) 765-NADA Outside USA (360) 254-0186 Fax: (360) 260-8620 Email:
[email protected] Web: www.acudetox.com Key words: Acudetox, acupuncture, detoxification, addictions, substance abuse, chemical dependency, treatment, adjunct treatment, NADA, National Acupuncture Detoxification Association, community health, behavioral health © National Acupuncture Detoxification Association 2008 All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without the prior permission of the National Acupuncture Detoxification Association or one of its designated agents. NADA only authorizes its designated Registered Trainers to provide NADA ADS training and considers the concepts and materials in this manual (unless duly attributed otherwise) to be the intellectual property of NADA. NADA gratefully acknowledges the many hands that contributed to this edition of our training manual, especially Michael O Smith, Carol Taub, Claudia Voyles, David Wurzel and Rachel Toomim. National Acupuncture Detoxification Association Acudetox Specialist Training Manual Table of Contents Section Title Introduction to the NADA ADS Training Manual Section I History The NADA Protocol Acudetox-based Treatment Model Page # Introduction 1 – 6 7 – 18 Acudetox – Auricular Acupuncture for Addictions and Behavioral Health Section II A Learning the NADA Protocol Point Descriptions and Locations Technique Mastery Trial Treatments and Clinical Experience Ear Seeds/Beads Sleep-Mix Tea 19 – 35 Section II B Learning the NADA Protocol Partnership with Clients Communal Treatment Approach / Effect Boundaries and Self Care Creating the Atmosphere Informed Consent and Client Information Documentation 36 – 43 Section III Public Health and Regulatory Concerns Exposure Control / Safety NADA Clean Needle Technique 44 – 49 Section IV Research and Acudetox Section V Integration and Sustainability Applications and Outcomes Integration with the Treatment Milieu Integration at a Systems Level The Acupuncture Interface Acupuncture as Innervention Program Sustainability 50 – 52 53 – 73 Section VI Oriental Medicine in the Context of Addictions and Behavioral Health and Treatment Introduction to Oriental Medical Concepts Oriental Medicine as Related to Behavioral Health and Recovery “Empty Fire” 74 – 78 Section VII Client Management Issues and Strategies Special Populations: Understanding Needs and the Role of Acudetox 79 – 92 Section VIII Ethical and Legal Issues ADS Pledge Confidentiality / HIPPA Consent to Treatment Compliance with All Federal, State and Local Regulations Supervision 93 – 98 Section IX The Nature of Addiction and Recovery Models for Understanding Addictions and Behavioral Health and Recovery Treatment Models Pharmacology of Psychoactive Substances 99 – 108 Section X Appendices A. B. C. D. E. F. G. H. I. J. The Lincoln Story Sample Client Information and Forms Acudetox Risk Management Research Excerpts from Treatment Improvement Protocol (TIP) 45 Special Populations Sample Program Forms Selected Manuscripts on Addiction and Recovery Supplies, Vendors and Publications References 109 – 189 National Acupuncture Detoxification Association © NADA 2008 Training Manual Introduction 1 Introduction to NADA and Acupuncture Detoxification Specialist Training Welcome to the National Acupuncture Detoxification Association (NADA) and this Acupuncture Detoxification Specialist (ADS) Training Manual. Facilitating training in the acudetox protocol was a key goal during the formation of NADA and it remains one of the primary objectives of the organization today. The training follows a curriculum adopted by NADA for the use of acupuncture in the fields of addictions and behavioral health. The competency-based training involves both didactic and clinical experience and is open to acupuncturists, physicians, nurses, psychologists, counselors, social workers, and other appropriate individuals as allowed by local regulations. The training emphasizes a clinical apprenticeship because coping with individual distractions and group process is of great importance and more difficult than the technical skill of repetitive needle insertion. ADS training is delivered by NADA designated Registered Trainers and represents an interactive learning process. A Certificate of Training Completion is granted by NADA to those individuals who successfully complete all of the training requirements and demonstrate the competencies outlined below. The National Acupuncture Detoxification Association Mission Statement The National Acupuncture Detoxification Association is an educational, not for profit, taxexempt corporation supporting education and training in a specific auricular acupuncture protocol integrated with comprehensive addictions and behavioral health treatment programs to relieve suffering during detoxification, prevent relapse and support recovery. NADA strives to make acudetox-based, barrier free addictions treatment accessible to all communities and to ensure its integration with other treatment modalities. The NADA mission exists to utilize the principles of both Oriental medicine and Western addictions and behavioral health models to bring significant benefit to persons in recovery from addictions and a variety of mental disorders. The NADA protocol, a simplified, standardized earneedling technique, derived from acupuncture specifically for this type of treatment, has been carefully developed and extensively tested. The word “nada” means “nothing” in Spanish. It signifies an abstinence-oriented, no-nonsense approach. (However, acudetox can be used in conjunction with almost any existing type of addiction therapy.) Nothingness is also one of the key tenants of Taoist philosophy. For example, it is said in the Tao Te Ching, that while a vessel is made from a lump of clay, it is the emptiness inside that makes it useful. This concept correlates well with the Alcoholics Anonymous (AA) principle of keeping life simple. The NADA Organization NADA is a membership organization of individuals who support the use of a five-point auricular acupuncture protocol – acudetox – in addictions and behavioral health treatment settings to alleviate suffering and to support recovery. NADA was founded and incorporated in 1985 as a membership and educational organization. As such, it has overseen the rapid spread of acudetox into an ever-expanding number of addictions National Acupuncture Detoxification Association © NADA 2008 Training Manual Introduction 2 and behavioral health treatment settings. Within these settings, acudetox has been shown to increase client retention and improve client outcomes. A diverse and dedicated Board of Directors guides NADA, with over 10,000 members and trained practitioners worldwide. More than 1500 clinical sites in the US, Canada, Europe, Asia, Africa, Australia, Latin America and the Caribbean currently use this protocol. NADA is committed to: • Providing training to a broad range of health care professionals and other qualified persons. If ADS trainings and practice were restricted to licensed acupuncturists and physicians, very few treatments would be done and a great resource would be lost. • Assuring professional standards and ethical application in the use of this modality, while striving toward increased access by those needing treatment. Acudetox is not a standalone intervention, but best combined with other addictions and behavioral health treatment modalities that meet the standards of the field. • Assuring that the principles of Oriental medicine and behavioral health and addictions treatment are integrated together in training and treatment/ application. • Maintaining a public service approach in ameliorating the plague of addictions that constitutes one of the most serious threats to the physical and social well being of society. Program Development NADA provides access to materials and consultation regarding implementing an acudetox-based treatment program. Available topics of consultation also include treating diverse populations, acupuncture for addictions research, criminal justice diversion programs, etc. Education Besides publishing its own newsletter, Guidepoints, NADA maintains a literature clearinghouse that offers hundreds of articles, tapes and videos on a range of related topics such as program development, treatment of special populations, trauma treatment, etc. Its national office arranges local, regional or national workshops, demonstrations and acudetox training courses and coordinates a speakers’ bureau of experts in the addictions, behavioral health and acupuncture fields. Curriculum development support for acupuncture schools, universities and addictions courses is also provided. The Association hosts an annual national conference for professional education, updates and sharing that offers CEU’s for acupuncturists and alcohol and drug addictions counselors. NADA participates in many national and international forums as well. On the Terminology Used Throughout This Manual Several different terms are used within the field for which the NADA acudetox protocol is generally used and often these terms are used interchangeably. For this purposes of the manual, the word addictions is the overarching term used to characterize the behavioral, physiological and psycho-spiritual aspects of this disease. Specific addictions to substances or behaviors are all included under this umbrella term. Another overarching term, behavioral health, is also used National Acupuncture Detoxification Association © NADA 2008 Training Manual Introduction 3 throughout this manual and refers to mental health conditions and treatment including but not limited to addictions. Throughout the evolution of NADA, the term for its style of ear acupuncture treatment has gone through several iterations. Acu detox, acu-detox, acudetox and other spellings have all been used at one time or another and will most likely continue to be used. In this manual, the spelling acudetox is used throughout to indicate this treatment modality. NADA Acudetox Treatment NADA-style treatment incorporates frequent acudetox sessions, an herbal tea blend and the use of ear seeds and/or magnetic beads all within the context of addictions and behavioral health treatment and prevention programs and mutual support fellowships. Acudetox involves the gentle placement of five small, sterilized, disposable stainless steel needles in specific sites on each ear of a client undergoing treatment. The recipients sit quietly in a group setting for 30 - 45 minutes. Acupuncture Detoxification Specialist (ADS) Training The ADS concept The NADA acudetox protocol is a simple, non-diagnostic modality that is readily taught to frontline treatment providers and is appropriate for behavioral health clientele. Many states in the US (including New York, Maryland, Virginia, Texas, Arizona and more than 20 others), Canadian provinces, and countries in Europe, Asia, Africa, Australia and South America have provisions for allowing non-acupuncturist ADSes to apply the acudetox protocol to addictions and/or behavioral health clients, generally under supervision of a licensed acupuncturist or physician. This forward thinking concept allows a much greater number of addictions and behavioral health clients to benefit from the acudetox modality than would otherwise be possible if the treatment were restricted to only licensed acupuncturists or physicians. Few addictions and behavioral health treatment programs can afford to hire licensed acupuncturists to do direct care. Allowing in-house addictions experts to offer acudetox also greatly enhances treatment relationships. While licensed acupuncturists and other healthcare providers whose professional scope of practice allows them to perform acupuncture can legally needle the five acudetox points without NADA training, NADA strongly recommends that all practitioners planning to provide acudetox be educated through the specialized NADA training. Understanding concepts and philosophies outlined in the training is vital to successful outcomes with this modality. Additionally, in jurisdictions where supervision of non-acupuncturist ADSes is required, the supervising acupuncturist or physician is often required to be NADA trained. Purpose of training It is NADA's privilege and responsibility to prepare well-qualified practitioners who can demonstrate the skills of acudetox. NADA developed and maintains a specialized training protocol to: 1. define the scope of practice of the Acupuncture Detoxification Specialist (ADS) for rendering services for addictions and behavioral health treatment through the provision of an adjunct auricular acupuncture intervention; National Acupuncture Detoxification Association © NADA 2008 Training Manual Introduction 4 2. promote the NADA client centered treatment approach: always respecting the dignity of the individual and the importance of developing the internal foundation for recovery; 3. address the public need for safe, accessible addictions and behavioral health treatment services by facilitating the appropriate training of ADSes and thereby expanding the availability of auricular acupuncture in those settings; 4. define basic competencies in order to assure minimum standards of acceptable preparation and practice; 5. establish a core curriculum that serves as criteria for fundamental and consistent training of ADSes. Scope of practice The title "Acupuncture Detoxification Specialist" (ADS) denotes one who is trained specifically in integrating the NADA “acudetox” auricular acupuncture protocol into addictions and behavioral health treatment and prevention (which may also be referred to as detoxification, chemical dependency treatment, dual-diagnosis, or substance abuse treatment.) Licensed acupuncturists or those healthcare practitioners permitted to perform acupuncture under the scope of practice of their professional licenses or certifications are generally permitted to administer acudetox in any setting to any type of client. The scope of conditions that non-acupuncturist ADSes may treat is limited to those that are related to addictions and behavioral health treatment, including detoxification, withdrawal, emotional trauma, craving, stress syndromes, relapse prevention, rehabilitation and recovery maintenance. This may include persons with coexisting chronic mental illness, HIV/AIDS, PTSD or persons at risk for substance abuse. Non-acupuncturist ADSes shall provide acudetox under the appropriate supervision and settings in compliance with local and/or state guidelines. Eligibility for NADA ADS training Individuals who work or intend to work within the addictions and behavioral health treatment fields are eligible for ADS training. One of the benefits of the NADA protocol lies in the simplicity and accessibility of its practice for a wide array of individuals, including but not limited to counselors, physicians, physician assistants, nurses, acupuncturists, social workers, detox technicians, psychologists, administrators, outreach workers, criminal justice workers, recovery readiness/harm reduction workers, case managers etc. The protocol can be safely and accurately integrated into a treatment milieu by a broad range of individuals with different roles and responsibilities within their respective organizations. Candidates with little or no prior experience may require additional training hours. The practice of acudetox is generally regulated by state agencies and it is up to the individual to ascertain whether it is legal for non-acupuncturist ADSes to perform the acudetox technique in his or her jurisdiction. Furthermore, it is up to the individual ADS or ADS trainee to insure that he or she remains in compliance with local regulations. National Acupuncture Detoxification Association © NADA 2008 Training Manual Introduction 5 Obtaining a Training Completion Certificate Every trainee must complete the combined didactic and clinical experience provided and/or overseen by a NADA Registered Trainer. In addition, he or she will demonstrate to the satisfaction of that Registered Trainer a mastery of the basic competencies listed below. Upon successful completion of all requirements (hours and competencies) and an application process, the ADS will receive a Certificate of Training as an Acupuncture Detoxification Specialist. Occasionally applicants are not able to demonstrate the required competencies even upon completion of the required hours of training. Such applicants will not be eligible to receive a certificate until they do so. Individuals may work with a Registered Trainer to identify deficits and in partnership create a plan that will allow the individuals to achieve appropriate mastery of the materials and techniques. PLEASE NOTE: The Training Completion Certificate indicates successful completion of NADA acudetox training and demonstration of entry-level skills. NADA does not provide initial or ongoing certification of ADSes. ADSes are encouraged to maintain competencies and continue to expand their knowledge by pursing continuing education, attending the NADA annual conferences and maintaining active annual membership in the organization. ADSes each sign an Ethics Pledge verifying the understanding of and agreeing to abide by rules regarding limited scope of practice as appropriate, confidentiality, client rapport and respectful treatment, financial interest, and sharing experiences with the NADA community. NADA asks that each trainee become a member of the organization. This membership, good for one year, entitles trainees to all the benefits of membership including the newsletter. Upon successfully completing training requirements and demonstrating mastery, the trainee submits to the NADA office an application for a training completion certificate, signed by the Registered Trainer, and a signed ethics pledge. ADS standards of competency 1. Able to perform at least 20 treatments during a 4-hour period with good point location and technique. 2. Able to explain the uses and limitations of the treatment. 3. Able to demonstrate sensitivity, compassion and respect for clients. 4. Able to understand the communal treatment effect and maintain an appropriate atmosphere. 5. Able to demonstrate clean needle technique. 6. Able to demonstrate familiarity with research and outcome results of NADA programs. 7. Able to demonstrate understanding of and to comply with, the limited scope of practice and other ethical principles. National Acupuncture Detoxification Association © NADA 2008 Training Manual Introduction 6 8. Able to demonstrate understanding of the implications of role of auricular acupuncture for addictions and behavioral health in the larger treatment context. 9. Able to write chart notes re: status, treatment given and client response. 10. Able to demonstrate understanding of the adjunctive nature of acudetox and the importance of collaboration and communication with the treatment team. 11. Able to demonstrate recognition of the psycho-spiritual nature of recovery and respect and support the client's internal process. 12. Able to modify treatment appropriately (e.g., fewer needles, shorter retention) and to respond to adverse clinical situations should they occur. 13. Able to demonstrate understanding of addictions and the NADA protocol from the perspective of basic concepts of Oriental medicine (Qi, yin/yang, empty fire). These competencies are considered the minimum skills that must be demonstrated to become an Acupuncture Detoxification Specialist. The trainee will further develop each of these skills as she or he begins to apply the training in a treatment setting. This is true whether the competency is the speed of inserting needles or achieving a greater level of sensitivity towards clients. NADA reserves the right to deny a Training Completion Certificate to anyone who, in the opinion of NADA and/or his or her Registered Trainer(s), does not fully demonstrate these minimum skills. National Acupuncture Detoxification Association © NADA 2008 Training Manual Section I: Acudetox 7 Auricular Acupuncture for Addictions and Behavioral Health Treatment History The NADA Treatment Protocol Acudetox-Based Treatment model National Acupuncture Detoxification Association © NADA 2008 Training Manual Section I: Acudetox 8 National Acupuncture Detoxification Association © NADA 2008 Lincoln Recovery Center History & Protocol Training Manual Section I: Acudetox 9 Acupuncture treatment for drug and alcohol problems was primarily developed at Lincoln Hospital, a city owned facility in the impoverished South Bronx. The Substance Abuse Division at Lincoln is a State licensed treatment program that has provided more than 500,000 acupuncture treatments in the past 30 years. Yoshiaki Omura was the consultant who began the program (Omura 1975). Initially, in 1974, Lincoln used H.L.Wen, MD's method. In the process of researching the effects of applying electrical stimulation to the lung point in the ear for post surgical pain, Wen discovered serendipitously that the acupuncture relieved opiate withdrawal symptoms (Wen 1973). When acupuncture was first introduced, Lincoln was a methadone detoxification program; therefore, acupuncture was initially used as an adjunctive treatment for prolonged withdrawal symptoms after a 10-day methadone detoxification cycle. Clients reported less malaise and better relaxation. Subsequently, twice daily acupuncture was added concurrently with tapering methadone doses. Reduction in opiate withdrawal symptoms and prolonged program retention were noted. It was accidentally discovered that electrical stimulation was not necessary to produce symptomatic relief. In fact, simple manual needling produced a more prolonged effect. Clients were able to use acupuncture only once a day and still experience a suppression of their withdrawal symptoms. A reduction in craving for alcohol and heroin was described for the first time. This observation corresponds to the general rule in acupuncture that strong stimulation has primarily a symptom-suppression or "sedation" effect and that more gentle stimulation has more of a long term, preventative or "tonification" effect. The ear acupuncture protocol was expanded by adding "Shen men" (spirit gate), a point well known for promoting relaxation. Other ear points were tried on the basis of lower resistance, pain sensitivity, and clinical indication during a several year developmental process. Michael O. Smith MD, DAc added the "Sympathetic", "Kidney" and "Liver" points to create a basic five-point formula. Numerous other point formulas using body acupuncture points were tried on an individual basis without any significant improvement. Smith also developed a companion herbal formula known as "Sleepmix tea". In 1978, the clinic relocated and discontinued the use of methadone as a part of its detoxification protocol. Over the ensuing years Lincoln further developed a client-centered acupuncture-assisted model of treatment. It became clear during the crack cocaine epidemic in the mid-1980's that the 5 point protocol was effective in assisting crack addicted persons to become and remain clean. Lincoln also functions as the largest training institute for Acupuncture Detoxification Specialists. Some 2000 ADSes from around the world were trained in this protocol at Lincoln, about 10 trainees per week. In 1997, the Lincoln Medical and Mental Health Center changed its name to Lincoln Recovery Center. Current services there include a comprehensive Maternal Substance Abuse Services (MSAS) program for women who are pregnant or referred by the local children's services administration and a Criminal Justice/General Detoxification Unit for both voluntary and National Acupuncture Detoxification Association © NADA 2008 Training Manual Section I: Acudetox 10 adjudicated clients. A Drug Abuse Information System component operates the on-site urinalysis equipment linked to the clinic's computer system. Daily objective testing enhances treatment. The Lincoln Hospital model can be summarized and defined as follows: • • • • ADS clinicians use three to five ear acupuncture points: Sympathetic, Shen Men, Kidney, Liver and Lung. Treatment is provided in a group setting for a duration of 40-45 minutes. Treatment is available without appointment Monday through Friday. Acudetox treatment is integrated with conventional elements of psychosocial rehabilitation. Several other components of the Lincoln program are ideally combined with acupuncture and represent the NADA treatment model. These items include: o a supportive non-confrontational approach to individual counseling; o an emphasis on Narcotics Anonymous and other 12 step activities early in the treatment process; o a lack of screening for "appropriate" patients; o the use of herbal "Sleepmix" tea; o the use of frequent toxicologies; o a willingness to work with court-related agencies; o a tolerant informal family-like atmosphere. Contact Information Lincoln Recovery Center 349 East 140th St. Bronx, New York 10454 (718) 993-3100 Michael O. Smith, Medical Director Rosa Reyes, Registered Trainer National Acupuncture Detoxification Association © NADA 2008 • • Training Manual Section I: Acudetox 11 Historical Highlights of Utilizing Acupuncture in the Behavioral Health Arena 1971: New York Times senior editor James Reston published his account of his appendectomy in Beijing that utilized acupuncture as an analgesic. 1972: Wen, Hsiang-Lai in Hong Kong discovered by chance that needles inserted in the ear – intended to be used as a preoperative anesthetic – abated physical withdrawal symptoms from opium. 1973: Wen and Cheung publish their results of treating 40 heroin and opium addicts with electropotentiated ear acupuncture in the Asian Journal of Medicine. The New York Times also ran an article on these findings including this quote from Wen, “We don’t claim it’s a cure for drug addiction. If we can treat the withdrawal symptoms, make the patient more comfortable, and alleviate their suffering, then we have achieved something. Our treatment is not the complete answer to drug addiction.” 1974: Lincoln Hospital Detox Program, Bronx NY, an outpatient methadone clinic since 1970 began using the Wen protocol. Michael O. Smith, MD a psychiatrist and medical director of Lincoln Detox Program began working with the acupuncture clinic. 1982: Smith, et al, published an article in The American Journal of Acupuncture describing the five ear points used in their work as well as points in the hands and feet for particular symptoms. 1985: The National Acupuncture Detoxification Association (NADA) is founded and incorporated by Michael Smith, MD and others to promote education and training of chemical dependency clinicians in the NADA ear acupuncture protocol. The term acudetox is given to this treatment. 1986: Fr. Thomas Edward Gafney, SJ established NADA-style program in Katmandu. As its first organizational activity, NADA conducted trainings at the Crow Agency and Pine Ridge Indian reservations. 1987: Bulluck, Culliton and Olander published research indicating the effectiveness of acupuncture in treating chronic addiction (see Appendix “D 1”). Portland Addictions Acupuncture Center established by David Eisen, LAc in Portland Oregon. 1989: Acudetox program initiated for jailed drug-offenders in Miami. This was followed shortly after by the opening of the Miami Drug Court with the Hon. Stanley Goldstein sitting on the bench. The State of New York adopted the first statute to allow non-acupuncturist ADSes to perform the acudetox technique. 1991: NADA held its first large-scale conference in Santa Barbara, CA. NADA-UK formed by John Tindell and Margaret Pinnington. First NADA Europe meeting held in Sweden with representatives attending from The United Kingdom, Germany, UK, Finland, Hungary, Russia and Sweden. 1993: The charter issue of Guidepoints was published. An acudetox program was inaugurated at the Bronx Psychiatric Hospital. The first National Drug Court Conference was held in Miami. 1994: The Oregon Gambling Treatment Program initiated an acudetox program. Alex Brumbaugh published Transformation and Recovery. 8th Special Report to Congress on • • • • • • • • • • National Acupuncture Detoxification Association © NADA 2008 Training Manual Section I: Acudetox 12 Alcohol and Health mentioned acupuncture as a potential treatment modality. NADA issued its first training manual. • 1995: NADA issued its initial list of 34 Registered Trainers. Ellinor Mitchell published Fighting Drub Abuse with Acupuncture (now out of print). NADA-UK began training “substance misuse teams” in Her Majesties Prisons, which resulted almost immediately in an 80% reduction of violent acts. Michael Smith, MD received first National Leadership Award from the National Association of Drug Court Professionals. 1996: Treatment Improvement Protocol Series 19 (TIP 19) published by the Center for Substance Abuse Treatment (CSAT) of The National Institutes of Health gave modest support for the use of acupuncture in opiate detoxification. GMHC released Points to Change video, which became a staple of NADA trainings. The first acudetox web page went online. 1997: The National Institutes of Health published Acupuncture. NIH Consensus Statement that includes the conclusion, “There are other situations such as addiction, … in which acupuncture may be useful as an adjunct treatment or an acceptable alternative or be included in a comprehensive management program.” 1998: Encyclopedia Britannica Medical and Health Annual published an article on acudetox authored by Michael O Smith, MD. The “Lessons Learned” series of essays by Claudia Voyles, LAc began appearing in Guidepoints. 1999: The Journal of Substance Abuse Treatment published an article by Schwartz, et al, on the value of acupuncture in substance abuse treatment (see Appendix “D 2”). 2000: The New York State Office of Mental Health formally added acudetox standards to state regulations. Jim Byrne, a volunteer from Lincoln Recovery, began NADA Ireland. 2001: Acudetox training capability established in India and Thailand for Burmese refugee camps. After the terrorist attacks on the World Trade Center, an acudetox for terrorism survivors program began in Manhattan providing over 1,000 treatments in the first 10 days and continued through 2007. 2002: Pan-African Projects brought NADA treatments to Uganda and surrounding regions. Transformation and Recovery had its second printing. The first methodologically sound NADA treatment report on smoking cessation with positive results appeared in American Journal of Public Health. The US Government reported 736 certified addictions treatment programs in the US offered acupuncture. Members of NADA Italy completed a study of smoking cessation. 2003: Substance Misuse Program in UK expanded to over 130 correctional facilities. NADA-style treatments in a residential program for street children in Peru expanded. Similar programs in Mexico City and Philippines also expanded services. Homeward Bound, Inc becomes a Training Center for NADA 2005: NADA members aided in Gulf Coast recovery efforts after hurricanes Katrina and Rita and in Kashmir following earthquakes. In Israel, NADA-style treatments expanded into several clinical institutions. Chiclayo Peru and Tijuana Mexico have formal training in Medical Schools/ Universities for MDs, Ph. Ds, and RNs. • • • • • • • • • National Acupuncture Detoxification Association © NADA 2008 • Training Manual Section I: Acudetox 13 2006: CSAT updated TIP 19 with TIP 45, which contains several sections discussing the use of acupuncture in detoxification and substance abuse treatment (See Appendix “E”). National Acupuncture Detoxification Association © NADA 2008 Training Manual Section I: Acudetox 14 National Acupuncture Detoxification Association © NADA 2008 • The NADA Acudetox Treatment Training Manual Section I: Acudetox 15 Acudetox involves a simple, standardized five-point auricular (ear) acupuncture modality. NADAstyle treatment incorporates frequent acudetox sessions, an herbal tea blend and the use of ear seeds and/or magnetic beads all within the context of addictions and behavioral health treatment and prevention programs and mutual support fellowships. Acudetox supports the treatment and recovery process by making the client stronger from the inside. • • • • • Acudetox involves the gentle placement of five small, sterilized, disposable stainless steel needles in specific sites on each ear of a client undergoing treatment. The recipients sit quietly in a group setting for 30 - 45 minutes. Treatment is offered frequently, even daily if possible initially. The treatment is a non-verbal process with minimal interaction between client and provider. The treatment benefit is immediate, tangible and apparent even to someone entering the treatment center for the first time, and can be provided as an initial treatment intervention before clients have developed a relationship with the counseling staff. Acudetox can be offered prior to an extended process of assessment and diagnosis. Acudetox has been shown to significantly decrease cravings for alcohol and drugs, withdrawal symptoms, relapse episodes, anxiety, insomnia and agitation. Acudetox often helps participants become relaxed and more comfortable with their own thoughts, enabling them to experience a sense of “letting go” of tensions and apprehensions, and supporting quiet participation in a group setting with others who are involved in the process of recovery. Acudetox facilitates relationships with self and others. Acudetox is effective regardless of the client’s level of motivation and tends to increase the client’s readiness and willingness to participate in treatment. Acudetox improves the effectiveness of other program components. Acupuncture needles don’t put anything into the client; rather they remind the client of what he or she already has. Acudetox opens up possibilities on the body, mind and spirit levels. • • • • • • • • National Acupuncture Detoxification Association © NADA 2008 Unique Benefits of Using Acudetox in Behavioral Health Settings Training Manual Section I: Acudetox 16 Effective across types of addictions • Outcome and anecdotal clinical reports indicate effectiveness with the commonly used addictive substances and combinations of substances, and with behavioral/process addictions such as gambling and sex addiction. Other interventions often target only specific drugs. Effective throughout the treatment/recovery process • Originally developed for detoxification, the NADA protocol has since shown efficacy when used in pre-treatment/harm reduction settings, throughout the stages of treatment and as a relapse prevention and support for ongoing long-term recovery. • It is consistent with 12-step recovery and other mutual support fellowships. Effective along the continuum of care • It has successfully been integrated with a wide range of addiction treatment models including those utilizing medications. Accessible to men, women and adolescents. Accessible cross-culturally. Treats the whole person – body, mind, spirit, and emotions – just as addiction impairs the whole person. It has a comprehensive, not compartmentalizing effect. Non-verbal and non-performance (while most other treatment interventions are both). Elicits immediate and long-term effects • With the exceptions of medications administered, few treatment processes yield immediate relief of suffering. Most promise future improvement. Few complications and adverse reactions. Non-addictive. Simple and flexible and inexpensive. Easily integrated into treatment settings. Improves treatment relationships and the treatment environment. Relieves staff stress. Improves treatment engagement, retention, and outcomes. AMA/APA rates decrease and successful completion rates increase. Paradoxically even more effective with the clients who are “hardest” to treat: • Effective intervention for persons who are pregnant, have co-occurring mental health or other medical diagnoses, are violent or otherwise involved with the criminal justice system, etc. Consistent and relatively safe. Balancing and not symptom, syndrome dependent. National Acupuncture Detoxification Association © NADA 2008 Psychosocial Characteristics of the Acudetox Protocol • Training Manual Section I: Acudetox 17 It is a non-verbal process. o The treatment will be just as helpful if the patient lies to us. o The treatment will be just as helpful if the patient is ashamed to speak about certain issues. o Patients will be able to learn about themselves and process troublesome issues more gradually and comfortably. The patients can be engaged in helpful treatment even before they are able to tolerate intense or personalized one to one interactions comfortably. o Needy, fearful patients can be engaged in treatment before they can tolerate a bonding relationship with staff. o Paranoid, antagonistic patients are able to accept help in spite of their lack of trust. o Patients with low self-esteem and a lack of hope can begin their treatment participation at a realistic level. o Patients who are also trauma victims will be able to participate in treatment even though they are fearful of interpersonal relations. o Hence a much wider selection of patients can be introduced to substance abuse treatment. Acupuncture provides a solution to some of the paradoxical problems in addiction treatment. o Patients can be treated before assessment and diagnosis are completed so that the patient can be calm and cooperative enough for a useful diagnosis to be made. o Confrontation about drug use is not necessary because a patient can be helped even while they are in denial about the need for treatment. o It is possible to provide kind, soothing, attention without the risk of enabling the addictive process. o Developing trust between the therapist and patient is much easier. o The patient can relax without losing control. o Indeed, the whole program can relax without losing control. Acupuncture helps the development of a meditation-like state. o Patients become comfortable with their own thoughts. o Patients become comfortable with their own physical processes. o Patients learn to "let go" of tension and preoccupations. o Patients develop their own spatial comfort zone. o Patients learn that their private, internal process can be a source of strength and renewal. o Patients are able to remain comfortable while focused on the present. o The calm stability in the acupuncture setting creates a relatively timeless process. There is much less pressure to improve according to certain standards. • • • • Acupuncture treatment in a group setting creates an environment that is reassuring and validating. As therapists, we are welcome to join this setting. We are able to be supportive witnesses for the patient's development. National Acupuncture Detoxification Association © NADA 2008 Training Manual Section I: Acudetox 18 o Hence patients listen, learn, and remember without being overwhelmed by distractions. o In summary, acupuncture helps patients participate in individual and group treatment sessions more effectively. • There are two components to acupuncture treatment. o A balancing process occurs almost immediately so that the patient is more receptive to the message of the treatment. o Very anxious patients usually fall asleep during acupuncture. o Tired, apathetic patients report an increased sense of vitality during and immediately after treatment. o Most people experience a relaxing and centering feeling. o As the number of treatment sessions increases, the patient will feel relatively harmonious most of the time. o Hence, experienced, successful patients will no longer fall asleep during sessions. These patients will also not need to have acupuncture as frequently to gain the same effect. o An outside observer might believe that acupuncture is less effective when the patient no longer falls asleep in the session. It is important to understand that just the opposite is the case. Acupuncture treatments become more effective as time passes. The phenomenon of "tolerance" which is so typical in pharmaceutical medicine is not present with acupuncture. o The actual "message" component of an acupuncture treatment often has a delayed onset of several hours. o As the patient becomes more balanced and receptive, this message becomes more effective over a longer period of time. Defining the mechanism of acupuncture as "stress relief" is a serious misunderstanding. o "Stress" is usually someone else's fault so that treating the victim of stress can only be temporary at best--like giving a child ice cream after the dentist. o All of our patients know that alcohol, heroin, cocaine are excellent "treatments" for stress. o Acupuncture is valuable because it helps the patient prepare for the future, not merely cope with the past. o We should judge the value of an acupuncture session not by the level of sedation during or after the session, but rather by how well prepared the patients are for counseling, groups, and other challenges. • Adapted from Michael 0. Smith, MD, DAc National Acupuncture Detoxification Association © NADA 2008 Training Manual Section I: Acudetox 19 National Acupuncture Detoxification Association © NADA 2008 Training Manual Section I: Acudetox 20 Clinical Effects of Acudetox: Clients Report: Relaxation Stress Reduction Craving Reduction Withdrawal Symptom Reduction Mental Clarity Increased Sense of Purpose/Wellbeing Better Sleep More Energy Better Appetite Program Effects of Acudetox: Programs report: APA/AMA rates drop Successful completion rates improve Client and staff satisfaction improves Incident reports decrease e.g., violent behavior and emergency calls PRN medication and dose increase requests decrease Medication compliance improves Clients engage more deeply in therapeutic activities Systems Effects of Acudetox (especially when staff and families are treated): Programs/relationships shifted. Staff burnout decreased. Staff who receive wellness benefit, report stress relief and decreased smoking, eating etc. Decrease staff turnover. Improved job satisfaction. Improved job performance Improved camaraderie and team building Fewer staff sick days. Clients are more present to family and community. Families are more engaged in their own recovery. Decreased criminal recidivism. National Acupuncture Detoxification Association Training Manual © NADA 2008 Section IIA: Learning the NADA Protocol 21 Learning the NADA Protocol Point Descriptions and Locations Technique Mastery Trial Treatments and Clinical Experience Ear Seeds/Beads Sleep-Mix Tea National Acupuncture Detoxification Association Training Manual © NADA 2008 Section IIA: Learning the NADA Protocol 22 National Acupuncture Detoxification Association Training Manual © NADA 2008 Section IIA: Learning the NADA Protocol 23 Auriculotherapy Auriculotherapy is a therapeutic modality in which stimulation of the external ear is utilized to alleviate health conditions in other parts of the body. The ear is considered to be a micro-system, like the hands and feet, a reflection of the entire body. In ear acupuncture there is an orderly, anatomical arrangement of points based on an inverted fetus or homunculus (little man) perspective in which the head is reflected on the lower part of the ear (lobe) the hands and feet towards the top and the internal organs located within the depressions of the outer ear. from the Auriculotherapy Manual by Terry Oleson National Acupuncture Detoxification Association Training Manual © NADA 2008 Section IIA: Learning the NADA Protocol 24 Auricular Topography and Landmarks (David Wurzel, LAc) National Acupuncture Detoxification Association Training Manual © NADA 2008 Section IIA: Learning the NADA Protocol 25 NADA EAR PROTOCOL The NADA five points were chosen based upon Oriental medical theory and clinical indication as well as lower electrical resistance and pain sensitivity. All the five points serve to balance the body’s energy and assist the body’s healing processes. Together the combined effect of the five point protocol is, as referred to in Oriental medicine, a yin tonification, restoring the calm inner qualities akin to serenity. In general, needling the Sympathetic and Shen Men points produces calming, relaxing and centering effects. The other three points, Kidney, Liver, and Lung, correspond to yin organ systems in Oriental medicine. The yin organs are seen as internal, nourishing, nurturing, restorative and supportive. They store the vital substances such as energy and essence. In modern Western medicine, kidney, liver and lung relate to detoxification and cleansing (the organs of elimination). All five points are easy to locate on the surface of the external ear. The points are found in the dark, deep, cavernous part of the ears and underneath ridges, i.e., the yin side. In general, the ear points are found at places where there is a change in the anatomical structure. These locations and changes become clear with a little practice. It is not necessary to memorize the names of the ear’s anatomical structures. Using a clock analogy; Shen Men is at 12:00, lower Lung at 6:00 and Liver at either 3:00 on the left ear or 9:00 on the right. National Acupuncture Detoxification Association Training Manual © NADA 2008 Section IIA: Learning the NADA Protocol 26 Overview: TheThe National Acupuncture Detoxification Sympathetic point balances the sympathetic and parasympathetic nervous systems. It has a strong analgesic (pain relieving) and relaxant effect upon internal organs and dilates blood vessels Sympathetic Point Acudetox Protocol National Acupuncture Detoxification Association Training Manual © NADA 2008 Section IIA: Learning the NADA Protocol 27 Sympathetic Point Location: Locate this point by following the line of the inferior antihelix crus, hidden under the rim of the helix. Insert the needle parallel to and along the inferior crus. Needle Technique: Possible needling challenge: If the rim of the helix is folded so close that it touches or almost touches the inferior antihelix crus – start with the tip of the needle at the superior helix crus and then slide it inferior to get the tip beneath the rim. Indications: • Body Level o Balances sympathetic nervous system, has a strong analgesic and relaxant effect upon internal organs and dilates blood vessels. • Mind Level o Reduces epinephrine/norepinephrine levels for relaxation • Spirit Level o Calms the spirit, provides for serenity (yin time) National Acupuncture Detoxification Association Training Manual © NADA 2008 Section IIA: Learning the NADA Protocol 28 Shen Men Overview: Shen Men translates roughly as spirit gate. Needling this point generally helps to alleviate anxiety and nervousness and produces a calming, relaxing effect. It helps the process of going within, supporting the internal journey of recovery. The point lies in the triangular fossa. The zone runs from just inside the tip of the “U” to one-third of the way along the superior antihelix crus, under the rim. The needle should be inserted either perpendicularly into or at a slight angle to the point Point Location: Needle Technique: Possible needling challenge: If the triangular fossa is very large or uneasily detected, then use a location that is directly in line with the Kidney point, at the half-way point between the lower edge of the inferior helix crus and the superior edge of the superior helix crus. If the triangular fossa is hidden or difficult to distinguish because of a large helix that folds over the superior crus, locate the point on a line superior to the Kidney point and place the needle superiorly at a 45° angle. Indications: • • • Body Level o Alleviates pain, tension, excessive sensitivity; reduces hypertension Mind Level o Calms the mind and relieves anxiety, depression, insomnia and restlessness Spirit Level o Opens connection to spirit (opens one’s heart); ability to love self and others National Acupuncture Detoxification Association Training Manual © NADA 2008 Section IIA: Learning the NADA Protocol 29 Kidney Point Overview: The kidney in Chinese medicine is associated with growth, development, reproduction, courage, intelligence and the aging process. It is believed to store the source energy and the essence, or Jing. It is associated with fear, resolve and the will. This hidden point lies within the superior concha under the anti-helix ridge, inferior to Shen men (along the axis of the ear). Observe the shape of the lower edge of the inferior helix crus. There is an increase in the angularity of that edge just above the location of the Kidney point. The needle is inserted at a 45° angle from vertical pointing towards the top of the head. Point Location: Needle Technique: Indications: • Body Level o Stimulates physiologic and hormonal functions • Mind Level o Influences mental state and happiness, relieves fear • Spirit Level o Reminds client of his or her will and intention to overcome the addictions; allows client to hear the positive National Acupuncture Detoxification Association Training Manual © NADA 2008 Section IIA: Learning the NADA Protocol 30 Liver Point Overview: Oriental medical theory associates the Liver with resolving anger and aggression and with keeping both the emotions and the body’s systems moving smoothly. It is responsible for planning, vision and insight. The point can be found by following the crus of the helix to the wall of the cavum concha. The zone includes the area superior and inferior to that point. (The practitioner will often need to visually extrapolate where the concha root would extend.) The needle may be inserted perpendicularly or at a slight angle to the ear. Be careful not to needle completely through the ear. Point Location: Needle Technique: Indications: • • • Body Level o Simulates physiologic and hormonal functions; relieves muscle cramps Mind Level o Aids in clear thinking and decision making; relieves frustration, depression, anger Spirit Level o Helps client connect with the internal self and find direction in life National Acupuncture Detoxification Association Training Manual © NADA 2008 Section IIA: Learning the NADA Protocol 31 Lung Point Overview: In addition to respiration, the Lung is also involved in immunity and protecting the body from disease. The Lung is associated with the grieving process and with letting go. It is responsible for inspiration, respect and connection with the heavens. The point is found in the middle of the lower region of the cavum concha inferior (relative to the ear axis) or just superior to the Heart point (the most central, deepest area of the cavum concha). Visually locate the deepest, most central portion of the cavum concha (the Heart Point) and insert the needle just below in line with Shen Men and Kidney along the axis of the ear (or just above the Heart point for the alternative location). Often the highest point on the anti-tragus can be used as a landmark to guide the needle into the inferior concha and directly to the Lung point. Point Location: Needle Technique: Indications: • • • Body Level o Lung is an important organ for detoxification; regulates pores Mind Level o Aids in regulation of grief/sadness; improves sense of connection and self respect and integrity Spirit Level o Reminds client of connection with heaven; provides inspiration National Acupuncture Detoxification Association Training Manual © NADA 2008 Section IIA: Learning the NADA Protocol 32 Acudetox Rapport and Needling Techniques • Be sure you are prepared, calm and focused. Have the needles ready for use. Always be mindful of your body positioning so that you are stable and introducing yourself into the client’s space appropriately. Approaching the client from the front and to the side tends to make him or her more comfortable than from straight-ahead or from behind. Be sure the client is prepared, sitting comfortably with both feet on the floor, upright and present to the treatment, with both ears already prepared with alcohol swabs (or cleaned with an alternative to alcohol if the client is on disulfam/Antabuse or Flagyl). Speak calmly, directly, in low tones, explaining the procedure to the client if it is his or her first treatment. Ask if the client is ready. If the answer is “no”, guide the client into taking several deep, long and relaxing breaths. A client with upper respiratory problems may not be able to take a deep breath. In this case, guide them to relax and breathe calmly. Make sure that you position yourself so you can needle the ear from the front –side of the client. You may ask the client to turn his or her head or move forward in the chair. Move your body if necessary being mindful of the other clients. Hold the needle handle with your thumb and index finger. Hold as far down the handle as possible without touching the shaft. Do not touch the needle tip. (You may use your other fingers to stabilize on the client’s ear or area around the ear. This can be grounding for you and the client and provide a message of safe touch.) Visualize the location of each point remembering these points are all on relatively yin surfaces of the ear (triangular fossa, cymba concha, cavum concha). These areas will generally look darker than the adjoining raised surfaces. Using the needle as a pointer, visually follow the needle tip to the Acudetox point. Ask the client to take a deep breath and on the exhalation insert the needle by touching the tip to the point and giving it a gentle turn clockwise. Insert the needle approximately 1/8 inch. Some clients prefer you coach them with the breathing; others prefer you insert the needles quickly without too much fuss. Using the exhalation during needle insertion may decrease the sensitivity. Some clients are quite fearful. Take your time with those clients, encouraging them (and yourself) to breathe deeply. Some clients experience an initial pinch that should subside after a moment. If the client continues to feel discomfort you may adjust the needles slightly. If a client is sensitive or flinches over a point, you may pause momentarily and encourage the client to tell you when ready for the next insertion. Some clients find that vigorously rubbing their ears prior to the alcohol swabbing helps to decrease the sensitivity. Insert the needles confidently, calmly and quickly. If a needle is hanging down loose you may return it to the original insertion angle and give an additional turn. • • • • • • • • • • • National Acupuncture Detoxification Association Training Manual © NADA 2008 Section IIA: Learning the NADA Protocol 33 • Avoid words like, “OOPS”, “SORRY”, and “UH OH” or telling the clients they have “good” or “bad” ears. Always remember that there is a person attached to the ear you are needling. After the needles are inserted, check to see if the person is all right – not woozy, flush or pale. Needles often fall out after insertion. If this occurs within the first few minutes, you may insert another, with the client’s permission, or leave it out as the point has already been stimulated. If a needle falls later in the session, do not re-needle. Fallen needles. All needles must be accounted for by the end of the session. Do not disrupt the client’s treatment unduly looking for lost needles. If the needle is not visible, wait until all the needles are removed at the end of treatment to search for it. If you recover a needle during treatment, follow the instructions provided by the agency for handling fallen needles to insure a proper needle count and proper disposal. Do not reach to remove a needle from a client’s body, especially the chest or lap areas. Verbally guide the client to retrieve the needle. You may ask for permission to remove a needle such as one on a collar or shoulder if the client cannot see it. If a client attempts to hand you a needle, do not take it from him or her. Make sure that the client places the needle in the hazardous waste container or another designated impermeable container safely and in a manner that does not put you at risk of a needle stick. • • • • National Acupuncture Detoxification Association Training Manual © NADA 2008 Section IIA: Learning the NADA Protocol 34 Needling Cautions: Clinical realities that require management and special consideration. Deficiency/weakness: Clients who are extremely “deficient” or weak may need a lighter treatment using seeds or fewer needles. For example, clients who are HIV positive or pregnant or just off a long, hard run of drug use may be weak and more sensitive to the needles. Fatigue/hunger: Encourage clients who are excessively fatigued to rest and clients who are excessively hungry to eat. Some programs supply food. Others explicitly instruct clients to eat a light meal prior to acupuncture treatment. Broken skin or bruising: When clients have pimples, cuts, sores, rashes, irritation, infection, bruises or hematomas (swelling containing blood), etc. at the point location, do not needle that point until the site has fully healed. If a client has a wart or scar tissue at a point location, likewise do not needle it. Hemophilia: Clients who are hemophiliacs or “bleeders” may still be treated even though there is some bleeding possible when needles are removed. Bleeding is minimal because of the minuscule size of the needle hole. It is appropriate to ask such clients about their medication compliance and monitor them more carefully. The same applies to clients on anti-coagulation medications. However, these conditions are not contraindications for acudetox. High/intoxicated: Clients who have just used or are still very intoxicated may not get as much benefit from the treatment. Fear of needles (Belanephobia): Clients with fear of needles may need additional support in order to feel safe with the needling process. Allow them to observe or speak with other clients. Breathing exercises and options such as just trying one needle, sitting without needles or using press seeds/balls can be helpful. Needling Complications: Managing adverse clinical manifestations due to Acudetox treatment. Needle shock (postural hypotension, vagal reaction, needle sickness or fainting): • • • • Although this occurs infrequently, always look for signs during and immediately after needle insertion. Symptoms include loss of color, sweating, dizziness, lightheaded sensation, nausea and fainting. Sometimes a client will just say, “I don’t feel so good.” If a client feels faint or faints while sitting up, calmly remove the needles as quickly as possible. Raise legs to a horizontal position and lower the head. It is recommended that clients be placed safely on the floor if possible (be sure there are no contaminated needles in the area on which the client will be lying), making sure that the airways are not obstructed. If client feels chilled, help him or her to stay warm. Symptoms resolve quickly and client may exhibit relaxed behavior as if a full treatment occurred. • • National Acupuncture Detoxification Association Training Manual © NADA 2008 Section IIA: Learning the NADA Protocol 35 • • Eating prior to treatment decreases the possibility of needle shock even further. Do not attempt to needle again in the same day. Hematoma (swelling due to bleeding under the skin): • May occur when a needle is removed. • Have the client apply pressure with a dry cotton ball. Needle through ear: • May occur on insertion, particular in the liver point. • Does not cause problems but may be disconcerting for the client. • Adjust depth of needle insertion – review needling technique. Infection: • Rare with proper infection control procedure. • Do not needle the infected site until it has healed. • Encourage client to clean and apply first aid or refer to medical personnel. Headache: • During treatment (headache that comes on shortly after insertion of needles), remove or loosen sympathetic point. • For post treatment headaches, first determine if this was a one-time occurrence or if it has happened several times. If it occurs after several treatments, do not insert the sympathetic point next time. If this does not help then try reducing the length of the treatment session. “Healing Crisis”. Hering’s Law of Cure: a theory out of homeopathy asserts that as the body, mind and spirit clear past trauma, a flare-up might occur. Sometimes a client will report a flaring up of symptoms, if so, it typically happens in the first 24 – 48 hours after treatment, will not last for more than 24 hours and will not be a new symptom. Rather than viewing a symptom as a negative, encourage the client to view it as part of the healing process. Often the client will feel significant improvement or change after such an event. If the symptom is new, or one that the client does not remember having before, encourage the client to contact an appropriate healthcare provider. Please refer to Appendix “C”: Acudetox Risk Management for further detail regarding the handling of needles and adverse events. National Acupuncture Detoxification Association Training Manual © NADA 2008 Section IIA: Learning the NADA Protocol 36 Ear Seeds or Magnetic Ear Beads Acudetox provides the most effective stimulation, however seeds or beads applied to the NADA protocol points may also provide support to clients. Seeds/beads are placed on the point and secured with a small piece of tape. The seed traditionally used are vaccaria (black radish) seeds. Beads vary in metal content, usually gold or silver, size and whether or not they are magnetized. Seeds or beads are non-invasive and have a milder effect than needles. Use them when a client is unwilling or unable to receive Acudetox and as a support to clients between needling sessions. They stimulate the points and provide a tool that the client may use when not at the program by gently pressing on the seed/beads. Seeds/beads may also be used for infants and children. Though ear seeds/beads provide a useful adjunct to the NADA protocol, they cannot replace the powerful effect of needling. One program in Chicago was forced to switch from needling to the use of seeds/beads due to a regulatory change and noted a 30% increase in the positive urinalysis rate. Seeds/beads may be left on for up to one week or taken off as desired. Place the seeds/beads on the points with instructions to clients regarding stimulation, removal and disposal. It is difficult to place a seed or bead on the sympathetic point, but all others are accessible. Using tweezers will facilitate the process. Caution clients regarding over-stimulation as it may break the skin. In recent years, practitioners have found ear magnets useful for many conditions including Attention Deficit Disorder (ADD), Attention Deficit Hyperactivity Disorder (ADHD), generalized anxiety, autism and violence in youth. Experience shows that placing a gold (or sometimes silver) magnet on the “Reverse Shen Men,” on the back side of the ear approximately behind the Shen Men point can have dramatic and lasting effect. National Acupuncture Detoxification Association Training Manual © NADA 2008 Section IIA: Learning the NADA Protocol 37 Sleepmix Tea Developed by Michael Smith, this tea is a natural blend of Western herbs formulated to help in detoxification, aid in digestion, prevent insomnia, promote relaxation and reduce stress. The mixture – 3 parts chamomile and 1 part each peppermint, yarrow, hops, skullcap and catnip – is reported to calm and soothe the nervous system, stimulate circulation and eliminate waste products. Because the ingredients are considered food compounds, there are no legal restrictions on the tea’s use. The formula can be used for the treatment of conventional stress and insomnia as well as providing an adjunctive support in addiction treatment settings. It has been shown to be particularly effective in the management of alcohol withdrawal symptoms (one facility discovered its seizure rate increased when the program ran out of tea). Programs can brew tea on site and/or offer teabags to clients to drink throughout the day reserving enough for a cup before going to bed. The constituents of Sleepmix tea have been reported to have the following effects: Hops: Yarrow: Catnip: Peppermint: Skullcap: Calm the nervous system, stimulate appetite, dispel gas and relieve intestinal cramps. Recommended for nervous diarrhea, insomnia and restlessness. Stimulate appetite; relieve stomach cramps, flatulence and gastritis, and to relieve gall bladder and liver problems by stimulating bile flow. Relieve upset stomach, colic, spasms, flatulence and stomach acidity. Useful for nervousness, insomnia, cramps, coughs, migraines, poor digestion, heartburn, nausea, abdominal pains, headaches and vomiting due to nervousness. Good for spasms, convulsions and nervous conditions such as excitability, insomnia and general restlessness. Also recommended for neuralgias and delirium tremens. Has been used for flatulence, colic, dyspepsia and restlessness. 1 teabag per cup of boiling water. Brew mild (steep 1 – 2 minutes) or strong (3 – 5 minutes). Drink hot or cool. If sweetening is desired, honey is preferred because of its yin qualities (avoid artificial sweeteners such as aspartame/NutraSweet and sucralose/Splenda). The taste of the tea may be considered slightly bitter with longer steeping times. Adding lemon may reduce the bitterness. May be used on a continual basis. Caffeine free. Will not cause a.m. drowsiness when used as a sleep aid. Sleepmix tea can be ordered from: Nutra-Control PO Box 1199 Old Chelsea Station New York, NY 10011 212-929-3780 Chamomile: Preparation: National Acupuncture Detoxification Association Training Manual © NADA 2008 Section IIA: Learning the NADA Protocol 38 National Acupuncture Detoxification Association Training Manual © NADA 2008 Section IIB: Learning the NADA Protocol 39 Learning the NADA Protocol Partnership with Clients Communal Treatment Approach/Effect Boundaries and Self-Care Creating the Atmosphere Informed Consent & Client Information Documentation National Acupuncture Detoxification Association Training Manual © NADA 2008 Section IIB: Learning the NADA Protocol 40 National Acupuncture Detoxification Association Training Manual © NADA 2008 Section IIB: Learning the NADA Protocol 41 ADS Relationships: The Spirit of NADA Beyond the actual needling treatment, a key element of the NADA protocol specifies qualities of behavior and attitude on the part of the clinician, consistent with what is known as the “Spirit of NADA”. Relationships with clients The NADA acudetox protocol is a way of being with clients in a much larger sense than just the application of the five ear needles. NADA-style treatment involves a partnership with the client towards supporting his or her transformation and recovery. Every aspect of an ADS’s interaction with persons in need, is to help them help themselves. Acudetox is a client-centered treatment that to be optimally successful requires practitioners to adopt the following principles: • Opening access to treatment. Eliminating unnecessary bureaucratic, socio-economic and environmental barriers to starting a program of recovery. Minimizing necessary ones as much as possible. • Understanding that the healing potential is within every client. • Using respectful communication and "chair-side" manner. Addressing client fear directly and minimizing discomfort. • Empowering client choices regarding acudetox. • Believing in the good and potential for change within clients, even when they themselves cannot. • Minimizing the importance of the practitioner by not interfering, taking ownership, or controlling the clients’ outcomes/processes. • Supporting and endorsing other recovery processes, including psychosocial interventions and mutual support fellowships (such as AA, NA and others). • Minimizing the intrusiveness of requirements. Keeping the "fussiness" of the process to a minimum to emphasize that the benefits come from within. Keep it simple. Get out of the way. • Minimize the verbal interaction to maximize the non-verbal experience. • Allow the client to have their own experience as long as it does not interfere with others, for example, allow them to sleep, read, fidget etc. • Creating opportunity for a wide range of client experience by not creating overt expectations (for example of "relaxation"), and by not doing other interventions during acudetox time. • Creating an environment conducive to acudetox and appropriate for the client population. Supporting yin nurturing treatment with a dimly lit, quiet room. • Support the communal treatment effect—the "group Qi". • Creating safety by maintaining appropriate boundaries. • Providing safe touch. Confining contact to the ear or head near the ear. National Acupuncture Detoxification Association Training Manual © NADA 2008 Section IIB: Learning the NADA Protocol 42 Relationship with self Working with addicted and recovering persons can be very challenging work. NADA recommends that ADSes develop their own forms of self-care to prevent burnout, reduce stress and maintain wellness. From a practical sense, it is nearly impossible to facilitate others’ healing beyond that which we ourselves are willing to do. Self-care techniques can include: • Receiving acudetox treatments. • • Attending Al-Anon or other 12-step fellowships. If you work with addicted clients you automatically qualify as an Al-Anon or Nar-Anon member. Working though issues raised by delivering acudetox. Doing this style of work may bring up the practitioners' own unresolved issues regarding trauma, codependence, etc. Addressing issues of discomfort such as difficulty inflicting pain or imposing program consequences. • Relationship with program Acudetox is not a stand-alone treatment for addictions and behavioral health. Acudetox works best when delivered within the context of current addictions and behavioral health treatment models, matched to the clients' particular medical and psychosocial needs. • Cultivating relationships with the treatment team • Communication regarding observations and clients needs • Seeking supervision as needed especially regarding safety, accuracy and clinically relevant issues. Please note: ADSes who are not licensed acupuncturists (or other healthcare practitioners whose scope of practice allows them practice acupuncture without supervision) must practice under supervision as required by state or local regulations. National Acupuncture Detoxification Association Training Manual © NADA 2008 Section IIB: Learning the NADA Protocol 43 National Acupuncture Detoxification Association Training Manual © NADA 2008 Section IIB: Learning the NADA Protocol 44 National Acupuncture Detoxification Association Training Manual © NADA 2008 Section IIB: Learning the NADA Protocol 45 National Acupuncture Detoxification Association Training Manual © NADA 2008 Section IIB: Learning the NADA Protocol 46 National Acupuncture Detoxification Association Training Manual © NADA 2008 Section IIB: Learning the NADA Protocol 47 Acudetox documentation “If it is not documented, it did not happen.” So says the old adage in healthcare provision. Proper documentation in the client treatment record in a manner consistent with other program components, state and local laws and HIPPA requirements allows acudetox to be a vital part of addictions and behavioral health treatment. Documentation facilitates communication with the program and other treatment providers. Documentation provides a clear picture of the course of treatment and represents an important part of risk management for treatment programs. Prior Informed Consent: It is essential that clients provide informed consent prior to receiving acudetox. The signed and witnessed consent form will be included in the client record. This may be a separate form or a specific acudetox reference in a general consent to treatment form used by a particular program (Appendix “G” includes sample forms). Programs that have ADStrainees providing direct client treatment should include that specification in the consent form language as well. Treatment Documentation: In general, minimum documentation of each acudetox needling treatment includes the date, treatment delivered (and/or if any of the 5 needles are left out or removed), client’s response to treatment (or any adverse events) and the ADS’s signature. Be sure to document any unusual occurrences or adverse events. Some programs developed forms to simplify the documentation process. Some programs use a SOAP (Subjective, Objective, Assessment, Plan) notes format. Client Response Documentation: Many programs gather information from clients in the form of evaluations, survey, symptoms checklists etc. These can provide valuable process and outcome information for program evaluation. Be careful about overburdening clients or staff with extra paperwork or gathering unnecessary information that never gets used. Clients should not be asked to fill out these forms while the needles are in. Needle Logs: Many programs also maintain a needle log to insure accountability of needles and document any lost needles. Incident reports are also to track missing needles and adverse events. Client Information/Instructions: Be sure to provide clients with clear information about the risks and benefits of acudetox and with clear instructions regarding what to do before, during and after the treatment sessions. Remind clients verbally and post program rules regarding client safety. Remind new clients prior to the first session. Instructions can be tailored to the program and clientele and include: • preparing their ears prior to treatment, • not playing with any needles that fall out during treatment, • securing their own fallen needles in whatever manner the program has established that protects others from contacting the contaminated needles. (e.g., placing them in a safe visible location, contacting the attending ADS, etc.), • avoiding contact with any needles that may be from someone else, • staying seated while the needles are in their ears, National Acupuncture Detoxification Association Training Manual © NADA 2008 Section IIB: Learning the NADA Protocol 48 • • • • not lying or sitting on the floor in the general area where needles may have fallen. (For clients with back problems, special arrangements can be made for the clients to lie down away from possible contact other clients’ fallen needles, using the restroom prior to treatment. If a client does need to use the restroom during treatment, or leave for any other reason, remove all needles. (The ADS may replace them with sterile, unused needles when the client returns if appropriate.) how to handle needle removal according to the program’s established protocol. how to behave during the treatment experience, i.e., silence or low talking, respect for others, what to do if they are uncomfortable, etc. National Acupuncture Detoxification Association Training Manual © NADA 2008 Section III: Public Health & Regulatory Concerns 49 Public Health, Safety and Regulatory Concerns Exposure Control/Safety NADA Clean Needle Technique See Appendix “C”: “Acudetox Risk Management”, for more complete details especially regarding program development. National Acupuncture Detoxification Association Training Manual © NADA 2008 Section III: Public Health & Regulatory Concerns 50 National Acupuncture Detoxification Association Training Manual © NADA 2008 Section III: Public Health & Regulatory Concerns 51 Acudetox Clean Needle and Exposure Control Procedures While acudetox is generally considered a relatively safe procedure, as is acupuncture in general, there is none-the-less certain inherent risks to which clients, ADSes, and cleaning personnel may be exposed. These risks include accidental needle sticks and exposure to blood borne pathogens, and improper handling and disposal of used needles and contaminated items. Exposure Control Plan. The Occupational Safety and Health Administration (OSHA) requires that all work settings that have a “reasonable risk” of exposure have a written plan for how to minimize such risk and what to do in the event of an exposure. Programs must develop and implement an appropriate Exposure Control Plan as required by OSHA, and also provide annual blood borne pathogens training to all personnel who have a reasonable risk of exposure to contaminated acupuncture needles and other materials that may have become contaminated by a patient’s blood or other body fluids. See Acudetox Risk Management, Appendix “C”, for further details on developing an exposure control plan and contacting OSHA. Programs, ADSes and acudetox supervisors must also be familiar with and abide by federal, state and local laws as they pertain to the acupuncture in general and acudetox in particular. The Exposure Control Plan includes a system for reporting exposure, information on testing for infection, treatment options available and monitoring for side effects of treatment. In developing the Exposure Control Plan, programs will evaluate the need for using gloves during needle removal. Factors to consider in whether to require gloves while removing needles include the type and number of clients served and the experience of the ADSes. Whether or not a program requires the use of gloves when removing needles, OSHA requires that gloves be available for workers if they desire to use them. Closed-toe shoes should be worn by ADSes to prevent inadvertent needle sticks from dropped needles. Universal precautions and blood borne pathogens The Centers for Disease Control and Prevention (CDC) define Universal Precautions as “a set of precautions designed to prevent transmission of human immunodeficiency virus (HIV), hepatitis B virus (HBV), and other blood borne pathogens when providing first aid or health care. Under universal precautions, blood and certain body fluids of all patients are considered potentially infectious for HIV, HBV and other blood borne pathogens” (Centers for Disease Control and Prevention, 2005). In other words, all human blood and certain other human body fluids are treated as if known to be infectious for blood borne pathogens. While Universal Precautions cover many types of body fluids, in acudetox settings blood is the fluid of concern as on occasion clients’ ears may bleed after the removal of the needles (Universal Precautions do not apply to sweat, tears, nasal secretions or saliva unless they contain visible blood). Universal Precautions include the use of Personal Protective Equipment such as gloves when there is a reasonable chance of the healthcare provider coming in contract with clients’ body fluids or contaminated items (defined as “the presence or reasonably anticipated presence of blood or other potentially infectious materials on an item or surface”) as well as measures to prevent inadvertent needle sticks. National Acupuncture Detoxification Association Training Manual © NADA 2008 Section III: Public Health & Regulatory Concerns 52 The Clean Needle Technique for Acupuncturists (CNT) is the recognized standard of care for the acupuncture profession in regards to blood borne pathogens and needle stick prevention (National Acupuncture Foundation, 1997). The 5th edition includes special provisions for performing acupuncture in public health settings that outlines specific modifications of the standard techniques. While this manual is the de facto standard for the acupuncture profession, as will be noted shortly, programs are required by federal law to abide by the regulations prescribed by OSHA and other federal entities. There are several factors that influence the overall risk of exposure to blood borne pathogens including the number of infected individuals in the client population, the pathogen involved, the type of exposure (e.g., needle stick versus skin contact), the amount of blood involved and number of blood contacts (Centers for Disease Control and Prevention, 2003). Several larger metropolitan areas report at least 90% of IV drug users are positive for HBV, hepatitis C (HCV) and/or HIV. Even so, very few exposures result in infection. Because acupuncture needles are solid (as opposed to hollow-bore hypodermic needles), they carry very little risk of carrying infected blood. With proper diligence inadvertent needle sticks with contaminated needles can be prevented. Proper disposal of blood-contaminated items such as used cotton balls further decrease the chances of blood borne pathogens exposure. Because of the high occurrence of HBV infection among IV drug users, the Centers for Disease Control and Prevention recommend universal HBV vaccination for individuals who work in facilities in which these clients are treated (Center for Disease Control and Prevention, Healthcare settings serving IDUs). Because the vaccinations are given via injection and therefore considered invasive, programs cannot mandate that their employees receive the vaccination series. ADSes are advised to consider the vaccination series if they have not already done so. Tuberculosis (TB) exposure is another concern in several metropolitan areas. The Centers for Disease Control and Prevention suggest that programs develop a TB exposure control plan designed to reduce the risk of TB transmission between clients and patients. Staff should be encouraged and can be required to undergo regular purified protein derivative (PPD) testing. Even very low risk programs should have a written procedure for how to proceed if a client with known or suspected active TB is encountered. National Acupuncture Detoxification Association Training Manual © NADA 2008 Section III: Public Health & Regulatory Concerns 53 NADA CLEAN NEEDLE TECHNIQUE Be Mindful. Be careful. Be focused and alert. Pay attention. Many accidents can be prevented by mindfulness and care. Keep your work areas clean. Have clearly outlined policies/procedures customized for the specific program and population. Use Universal Precautions and avoid contact with all blood. Wear closed-toed shoes. Before acudetox: Set up the room. Be sure that you have all the supplies necessary including hand cleaner/sanitizer, biomedical waste containers, cotton balls/swabs, gloves and lined trashcans. Wash your hands thoroughly with anti-bacterial soap before beginning the session. During acudetox: Have clients prepare their ears with alcohol swab. Allow to dry naturally. Clients on disulfam/Antabuse or Flagyl can use a non-alcohol-based preparation or use soap and water. Wash/clean your hands during the session as needed. If no hand washing station is available in the room, use alcohol-based hand rubs or antibacterial gel, wipes or foam between clients and/or after contact with anything except supplies. Wear gloves if you have any open sores/wounds on your hands that might come in contact with clients. Use only pre-sterilized, single-use needles from unopened packages. Dispose of any needles if you have any doubt of their sterility. Touch only the handle. Discard any needles if the tips touch any surface other than the intended ear point. Discard any unused, opened needles at the end of the treatment day. (Note, no bleeding occurs during needle insertion). Use good needle technique (see Section IIA). Provide clear client instruction. Make sure that clients are aware of how to respond during the treatment session, including what to do if a needle falls out or if they require assistance. Ask clients to sit upright with both feet on the floor while being needled. (They can adopt a more comfortable position after the needles are in.) It is recommended that clients not lie down in the general needling area. If a client has a physical need to lie down, try to position that person as safely as possible and be sure to account for all needles used.) Remain in the room and alert to client's needs. You are responsible for your own and your clients' safety during the treatment session. Do not leave clients unattended during acudetox. Minimize fallen needles by minimizing client movement during treatment. If a client needs to leave the room for any reason, remove all the needles first. Use extreme care when retrieving fallen needles to minimize the risk of a needle-stick. Use a magnet, hemostat or tweezers to pick up stray needles. (Use hemostats or tweezers to remove needles from magnets.) Do not take a needle from someone's hand. Have client's place needles into impermeable containers for disposal or directly into a sharps container. Follow your program's Exposure Control Policy should a needle-stick occur. National Acupuncture Detoxification Association Training Manual © NADA 2008 Section III: Public Health & Regulatory Concerns 54 Needle removal presents the highest risk for exposure. The practitioner or the clients can remove needles. There are risks and benefits of each model. (Programs will need to set policy/procedure that best suits their situations.) • Clients remove needles: Under supervision, clients remove their own needles and staunch any bleeding that occurs (using either a cotton ball or a cotton-tipped swab). It may be helpful to provide a station with a mirror, a biohazard container, cotton balls/swabs and hand cleaner, and a system for counting needles. Clients wash their hands with soap and water, alcohol-based hand rubs, antibacterial gel, wipes or foam after removing needles whether or not there was visible blood present. ADSes remove needles: ADSes remove needles one at a time and put each needle directly into the red sharps container watching it all the way into the container. (Whether or not the ADSes are required to wear gloves must be part of the program’s Exposure Control Plan. Have gloves available regardless.) Always have cotton balls or cottontipped swabs ready in your hand. Give cotton balls to client to staunch bleeding or hold a swab on the site for several seconds with firm pressure. If the ADS is wearing gloves and any blood gets on them, dispose of the gloves as outlined in the program’s Exposure Control Plan and don a fresh pair before going on to the next client (please note that while they prevent contact with blood, gloves do not protect against needle sticks). If the ADS gets blood on his or her hands, then implement the procedures outlined in the program’s Exposure Control Plan. • Bleeding. Usually bleeding involves just a few drops of blood and occurs immediately after the needles are removed. Bleeding occurs 10-20% of the time and does not indicate poor needling technique. (Holding or pressing a cotton ball/swab on the point for 10-15 seconds will usually suffice.) Delayed bleeding may occur. Monitor clients after needle removal and before they leave the premises. Account for all needles used. There are many ways to insure the count. Each program can adopt a procedure best suited to its needs. Handle contaminated items with extreme care as prescribed by the program’s Exposure Control Plan. Blood saturated items go into a biomedical waste container. Clean any exposed surfaces with anti-bacterial agents or bleach wash. Use only approved red Biohazard waste containers and approved disposal service or equivalent. Discard all needles whether exposed or not into the hard red plastic “sharps” containers. Watch the needle all the way into the container. You can carry sharps containers directly to the client or use small puncture-proof containers to collect from each client and then transfer needles into the sharps container. (Transfer containers should be sanitized between sessions or discarded appropriately.) Do not overfill sharps containers. After acudetox: Double check the room for any stray needles or contaminated materials. Sweeping with a broom or magnet can be useful. Secure and account for all supplies and waste. Dispose of unused needles. Secure biomedical waste containers. Double bag all trash and remove it from the room. National Acupuncture Detoxification Association Training Manual © NADA 2008 Section III: Public Health & Regulatory Concerns 55 Wash your hands thoroughly. Please note: Each program that provides acudetox needs to have a written Exposure Plan in place that dictates policies/procedures related to acudetox and the handling of needles and contaminated items, and a policy for what steps to follow should a needle-stick or blood exposure occur. Each ADS should consider the risks of exposure involved in doing acudetox and be familiar and comfortable with the program's plan. A note on grooming: ADSes need to keep their fingernails short and clean to maximize dexterity and minimize the risk of contamination. Avoid wearing jewelry, clothing or hair styles that might touch the client during treatment delivery. National Acupuncture Detoxification Association Training Manual © NADA 2008 Section III: Public Health & Regulatory Concerns 56 National Acupuncture Detoxification Association © NADA 2008 Training Manual Section IV: Research 57 Research and Acudetox Research monographs are found in the appendices National Acupuncture Detoxification Association © NADA 2008 Training Manual Section IV: Research 58 National Acupuncture Detoxification Association © NADA 2008 Research and Acudetox (Includes excerpted material from Smith, Brewington, Culliton 1998) Training Manual Section IV: Research 59 Research, (a term often used broadly and inaccurately), specifically refers to a Western scientific method of demonstrating the effectiveness of an intervention. Developed and more relevant for testing medications, the “gold standard” of research is the randomized, double blind, controlled trial. Carefully matched participants are randomly assigned to the study’s comparison groups. A “control” group receives a placebo or “sham” treatment. Good research requires considerable expertise and expense. The best designed studies involve a large sample of subjects, a variety of measurements with a preference for biomedical markers rather than just subject responses, follow-up over a long period of time and elaborate statistical analysis. These carefully designed studies therefore may have little resemblance to real-world, clinical practice. In terms of “sham” acupuncture, ear acupuncture charts indicate that all the surface areas of the ear are active treatment locations, so “sham” or “placebo” points can only be relatively less effective as opposed to inert substances used as placebos for studying medications. Although there is a small but growing body of studies on acudetox the results are mixed and difficult to decipher. The existing studies differ widely in the treatment delivered and the outcomes measured. H.L. Wen of Hong Kong was the first physician to report successful treatment of addiction withdrawal symptoms with acupuncture (Wen, 1973). He observed that an opium addict receiving electro acupuncture as pre-surgical analgesia experienced relief of withdrawal symptoms. The point stimulated was the ear acupuncture point corresponding to the Lung. Subsequently Wen conducted several basic clinical pilot studies which formed the basis of subsequent research. Results from then available placebo-designed studies support the conclusion that acupuncture’s effectiveness in facilitating abstinence with alcohol, opiate and cocaine addicted subjects is not due to a simple placebo effect (Brewington, 1994). Bullock (1987) studied 54 chronic alcohol abusers in an inpatient (although they could leave during the day), AA-based setting that were randomly assigned to either acudetox treatment or needling at nearby ear points (the “sham” group). Acudetox receivers showed significantly better outcomes regarding attendance, self-reported desire for alcohol and drinking episodes, and readmission for detoxification. Bullock (1989) replicated that study with 80 chronic alcohol abusers. Twenty-one (21) of the 40 patients in the acudetox group completed the 8 week treatment program as compared to 1 of the 40 sham in the sham group. Sham receivers self reported twice the number of drinking episodes and were more than twice as likely to be readmitted for detoxification within 6 months. (See Appendix “D”). This study, published in the esteemed British medical journal, The Lancet, garnered considerable attention and credibility for acudetox. National Acupuncture Detoxification Association © NADA 2008 Training Manual Section IV: Research 60 Washburn (1993) reported that opiate addicted individuals receiving correct site acupuncture showed significantly better program attendance relative to subjects receiving acupuncture on placebo sites. Konefal (1995) examined the efficacy of different ear acupuncture protocols with patients with various addiction problems. Subjects (n=321) were randomly assigned to one of three groups; a one needle protocol using the Shen Men point; the five-needle NADA acudetox protocol; or the five-needle acudetox protocol plus selected body points for self-reported symptoms. All groups showed an increase in the proportion of drug-free urine tests over the course of treatment. (Subjects with the single needle protocol showed significantly less improvement compared to the other two groups.) Shwartz, Saitz, Mulvey and Brannigan (1999) published a multi-variant, retrospective cohort study of 8,011 clients discharged from publicly funded detoxification programs in Boston. Comparison of outpatient (acudetox plus traditional detoxification/counseling) programs with residential (short-term detoxification without acudetox), showed acudetox recipients less likely to relapse. Only 18% of the acudetox clients readmitted to treatment within six months as opposed to 36% of the residential clients. (See Appendix “D”) A pilot study in Klamath Falls, Oregon by Russell, Sharp and Gilbertson (2000) of 86 addicted clients with chronic histories of arrest found a statistically significant increase in program retention for acudetox outpatient treatment as opposed to a historical no-acupuncture control group. Researchers noted positive trends towards fewer new arrests, fewer positive urinalysis results, and a shorter time needed to move through treatment phases/levels. A Yale University study (Avants, 2000) of 82 cocaine-dependent methadone-maintained subjects, randomly assigned to three groups, found statistically significant results for cocainefree urines: fifty-eight (58 %) of the acudetox group as compared to 24% of the sham control group and 9% of the relaxation video control group. The Yale study was a pilot for a larger, six-site nationwide study that yielded less favorable findings (Margolin, et al, 2002). This trial published in Journal of the American Medical Association (JAMA) found no statistically significant difference between the acudetox group and the control groups concluding, “Our study therefore does not support the use of acupuncture as a stand-alone treatment for cocaine addiction.” (Of note, between the first Yale study and the larger study, the protocol was modified slightly with less clinical recovery support offered to the study subjects and with reimbursement for study participation regardless of use. The study’s conclusion is noteworthy in that NADA has always supported the concept and practice of acudetox as an adjunctive treatment which should not be used as a stand-alone recovery intervention.) Researchers in Arizona (Bier et al, 2002) studied acudetox for nicotine dependent subjects (141). At one month, 10% of subjects receiving acudetox only were not smoking as compared to those receiving sham acupuncture along with education/counseling (22%) or those receiving real acudetox along with the clinical intervention (40%). National Acupuncture Detoxification Association © NADA 2008 Training Manual Section V: Integration 61 Integration and Sustainability Applications and Outcomes Integration with the Treatment Milieu Integration at a Systems Level The Acupuncture Interface Acupuncture as “Innervention” Program Sustainability Available from the NADA Literature Clearinghouse: Smith (1993), Acupuncture Helps Programs More Than Patients. National Acupuncture Detoxification Association © NADA 2008 Training Manual Section V: Integration 62 National Acupuncture Detoxification Association © NADA 2008 Applications and Outcomes Training Manual Section V: Integration 63 While originally discovered and developed as an adjunct intervention for acute opiate withdrawal, acudetox has since proved an effective tool across various addictions, both substance and behavioral “process” type addictions, across different client populations, and across the continuum of care. Over the last thirty years, NADA practitioners have found acudetox helpful in treating persons dependent upon opiates, alcohol, cocaine, poly-substances, marijuana, methamphetamine, prescription medication, as well as those addicted to acting out with food, sex, gambling, etc. Acudetox is not a stand-alone treatment. NADA’s experience with continued use of the protocol in a variety of settings worldwide since the mid-1970’s confirms that the integration of acudetox into addictions and behavioral health treatment programs generally improves client retention, client and staff satisfaction, and program outcomes. Anecdotal evidence confirms that acudetox generally facilitates the recovery process. Acudetox within the Continuum of care/stages of recovery Harm reduction, pre-recovery: Programs typically offer acudetox as a support within harm reduction settings that focus on health/safety, rather than on getting and staying sober. Examples of harm reduction programs include needle exchange, outreach programs, HIV education, drop in centers, homeless shelters, etc. Acudetox added to these programs often yields increased engagement and retention and improved likelihood that persons will enter into some form of treatment. Even in setting for which attendance and therefore treatment may be erratic, Acudetox serves to move the person towards a more proactive state. Acute detoxification settings, including hospital based and other medically managed programs: Detoxification programs typically offer frequent acudetox, at least once or twice daily. Some programs offer one regularly scheduled group session and additional ear treatments delivered by the clinical or nursing/medical staff as needed. Clients report decreased withdrawal symptoms and craving, and use less PRN (as needed) medication. Clients are more likely to complete successfully and graduate to the next level of care. Hooper Foundation (Portland, OR) cited a decrease from 25% to 6 % in recidivism after adding acudetox to their inpatient county detoxification program. Kent-Sussex (in Delaware) reported a decrease in recidivism from 87% to 18%. Sleepmix tea helped to mitigate withdrawal symptoms and improve sleep. Early recovery settings, outpatient and inpatient/residential: These types of programs typically offer frequent acudetox, daily or almost daily (5x/week) especially if they offer intensive levels of psychosocial care. With acudetox, fewer clients leave against advice. (AMA rates go down) and successful program completion rates go up. The Portland Alternative Health Center/Portland Addiction Acupuncture Clinic (OR) reported an overall program completion rate of 43.6%, as compared to 24% countywide in 1999. The completion rate climbed to 71% for clients who also were placed in alcohol/drug free housing. National Acupuncture Detoxification Association © NADA 2008 Training Manual Section V: Integration 64 Yonkers General Hospital (now Riverside Behavioral Health Center, Yonkers, NY) reported that 95% of clients found acudetox “helpful or very helpful”. Clinical staff reported clients had less denial and were actively engaged in the treatment milieu. Clients who got acudetox moved more quickly through stages. Penn North Wellness Center (Baltimore, MD), an inner-city outpatient acudetox-based program, documented that for 206 clients with prior criminal records and a documented average of 4.3 arrests/person, 97% had no new arrests in the five months after intake (an estimated average of .37 arrests/person). Maintenance/ongoing recovery programs: Acudetox may be offered more or less frequently, as other psychosocial interventions vary according to client need. Crouse Hospital (Syracuse, NY) counted 2700 acudetox treatments in the year 2000 for methadone maintained clients. Acudetox recipients had 22% positive urine samples as compared with 47% positive for the overall rate. Acudetox can be offered on an as needed basis as part of relapse prevention planning. Many acudetox programs offer the treatment as an ongoing support to graduate or “aftercare” clients and encourage those persons to come for ear treatments whenever they may need additional support or to get back on course if they do relapse. Acudetox with Specific Addictions (Based on clinical experience at Lincoln Recovery Center or observations of programs by the authors unless otherwise noted.) Opiate Addiction: Lincoln Recovery Center began by treating opiate addiction in 1974 inspired by the work of Wen with opiate addicted patients in Hong Kong. Acudetox provides nearly complete relief of observable acute opiate withdrawal symptoms in 5-30 minutes, and lasts for 8 -24 hours. The duration of the effect increases with the number of serial treatments provided. Recipients often sleep during the session and may feel hungry afterward. Patients who are acutely intoxicated at the time of treatment will behave in a much less intoxicated manner after the session and report feeling gratified, in contrast to reports of discomfort after Narcan administration. In acute opiate detoxification settings, acudetox is typically administered 2-3 times daily. Alternatively, it can be administered only once per day along with Clonidine or Methadone or other medication protocols on an outpatient basis. Many clients do well with daily acudetox because they taper their illicit opiate usage over a 3-4 day period. The addition of acudetox to an opiate detoxification program typically leads to a 50% increase in retention of completion of the recommended length of stay. Program retention is most strongly correlated with treatment success. Methadone maintenance: National Acupuncture Detoxification Association © NADA 2008 Training Manual Section V: Integration 65 Acudetox can be integrated into a number of different methadone-assisted treatment programs. Patients report a decrease in secondary symptoms of methadone such as constipation, sweating, and sleep problems. Typically there is a substantial drop in requests for symptomatic medication. Treatment staff usually notices decreased hostility and increased compliance in acudetox recipients. The most important impact of acudetox in methadone programs is the reduction of secondary substance abuse, usually involving alcohol and cocaine, even in patients with minimal motivation (Margolin, 1993). Acudetox is effective with patients on any level of methadone, buprenorphine or other medication protocol. Methadone withdrawal is notable for unpredictable variations in symptoms and significant postwithdrawal malaise. Acudetox helps clients to manage their fear and withdrawal symptoms and increase their ability to participate in the psycho-social supports necessary to recovery. Alcohol addiction: Alcohol withdrawal can be life-threatening. Directors of the acudetox assisted social setting detox program conducted by the Tulalip Tribe of Marysville, Washington estimate a yearly saving of $148,000 due to decreased referrals to hospital programs. Inpatient alcohol detoxification units typically combine acudetox and herbal Sleepmix tea with a tapering benzodiazepine protocol. Patients report few symptoms and better sleep. Their vital signs stabilize and they need less benzodiazepines. One residential program in Connecticut noted a 90% reduction in Valium demand when the herbal tea alone was added to their protocol. Retention of alcohol detoxification clients generally increases by 50% when an acudetox component is added to conventional settings. Some alcoholics receiving acudetox report a resultant aversion to alcohol. Woodhull Hospital in Brooklyn reported that 94% of the patients in the acudetox receiving group remained abstinent as compared to 43% of the control group who received only conventional outpatient services. Bullock (1989) showed a 52% retention of alcoholic patients receiving true acudetox, as compared to a 2% “sham” acudetox retention rate. Cocaine addiction: Acudetox recipients report more calmness and reduced craving for cocaine even after the first treatment. The acute psychological indications of cocaine toxicity are visibly reduced during the treatment session. The improvement is sustained for a variable length of time after the first acudetox treatment. After 3-7 sequential treatments, the anti-craving effect is more-or-less continuous with ongoing regular acudetox. A study of cocaine-dependent methadone maintained patients receiving 8 weeks of acudetox found a 44% overall abstinence rate. Abstainers reported decreased depression, a shift in selfdefinition, decreased craving and increased aversion to cocaine-related cues (Margolin, 1993). Urinalysis results at Lincoln Recovery Center for 226 cocaine and crack addicted persons who had received more than 20 acudetox treatments found that 149 had more than 80% negative urine screen tests for their entire treatment involvement and 39 more had at least 80% clean urine results for the two weeks prior to data collection. National Acupuncture Detoxification Association © NADA 2008 Training Manual Section V: Integration 66 Acudetox can lead to dramatic increases in treatment retention for cocaine addicted clients. A program for pregnant, crack-using women in NYC, Women in Need, reported the following: • • • . an average of 3 visits for conventional outpatient treatment only an average of 27 visits/year for acudetox along with conventional treatment an average of 67 visits per year for those who received acudetox, conventional treatment and an educational component. Methamphetamine addiction: Acudetox affords a similar dramatic increase in retention for methamphetamine addicted persons. Hooper Foundation, a public detoxification program in Portland, OR, reported 5% retention of methamphetamine users prior to the use of acudetox, and 90% retention after the addition of acudetox. The program noted increased psychological stability and decreased craving. Marijuana addiction: Primary marijuana addicted persons usually report a rapid reduction in craving and an improved sense of mental well-being from acudetox. Secondary marijuana use is usually eliminated along with the detoxification of the primary drug, e.g., cocaine. National Acupuncture Detoxification Association © NADA 2008 Integration with the Treatment Milieu Integration at a Systems Level THE ACUPUNCTURE INTERFACE Training Manual Section V: Integration 67 Some therapeutic processes transcend all treatment protocols and modalities. Acupuncture is among these. We will review these processes to gain clinical understanding of the role of acupuncture as a complement to them. • Group. Group dynamics are a powerful therapeutic mechanism in recovery and establish a ground for healing relationship. This dynamic is fundamental to our success with acupuncture in this field. It provides an opportunity for group process, without expectations placed on participants. The creation of a “safe group”, which for a practicing addict is a contradiction in terms, creates a positive paradox as an introduction to recovery. Intervention. Developed in Minnesota in the 1970’s, it is a process that involves “significant others” in a carefully planned and orchestrated confrontation with the “identified patient”. Admission to a treatment facility is made an ultimatum. The concept of intervention is a major treatment breakthrough because it acknowledges the addictive family system. A skilled intervention counselor will use the intervention as an opportunity to heal the system itself. Intervention is based upon the premise that the most endemic feature of the addictive system is denial – it is the foundation symptom of alcoholism/addiction. Denial does not necessarily refer to the use of the drug. Most addicts will admit to use. Clinical denial refers to the consequences of the addictive use. “Hitting bottom” means that the consequences of the chronic use have created the conscious connection between use and consequences of use. At this point, denial can be broken. (Drug courts make use of the opportunity of arrest to create a “bottom” for the addict.) Acupuncture as “Innervention” In our view of recovery, we always assume the motivation is present, regardless of the level of denial, the identification with addictive behavior, or how fearful the patient is of letting go of the addictive ground. There is always a deeper, wiser part of the person to which the intervention speaks. The acupuncture intervention/”innervention” invite the individual’s attention toward the inner resources of healing. Acupuncture can be seen as physical intervention on a level that addresses the core issue of the disease of addiction. Chronic drug use requires denial for its continued survival. • National Acupuncture Detoxification Association © NADA 2008 Training Manual Section V: Integration 68 It is virtually impossible to be accepting of, in touch with, and responsive to one’s body and chronically use psychoactive drugs. Acupuncture, as it has evolved in the public health/group setting with the NADA protocol has the added potential of opening up the addictive system of isolated external energy. The Qi flows outward, yin energy is nourished and is manifest in the room, and for the moment, the focus shifts, and there is the possibility of the consciousness of unspoken connectedness and participation. • Relapse Prevention. Born, in part, by the failure of treatment as a result of its focus on the detoxification and first 30 days of recovery. Clients often negotiate the early phases of recovery successfully, only to relapse on release from the program or shortly thereafter. Relapse prevention, as a focus, is also due to the increasingly sophisticated research on the persistence, into abstinence, of the discreet alterations of neurotransmitting mechanisms that result from drug use. Alcoholism/Addiction is a disease characterized by relapse. Phases of Recovery – Three General Phases of Recovery • Transition • Stabilization • Empowerment Acupuncture can be integrated with traditional treatment to enhance recovery at each phase. Our experience with the NADA protocol has led us to go by a less “use specific” definition of transition. Rather than a static event – abstinence, we emphasize the notion of recovery as process. Our suggestion is that the transition phase begins with the consciousness of the consequences of addictive drug use and extends for weeks, months or even years and is unique to each individual. Transition is a scenario of balancing physical and emotional extremes. It is the time required for the addict to become relatively comfortable with the idea of abstinence. It is a period characterized by slips and starts. • Detoxification/Acute Withdrawal. This is a subset of the transition phase, lasting from 3 to 15 days following abstention. Michael O. Smith MD calls it a “crisis in elimination” and relates to the body’s homeostatic efforts to achieve balance in the sudden absence of the chemical. The recommended treatment for the detoxification period is daily auricular acupuncture according to the NADA protocol. The transition phase is a period of radical center-seeking. Clients weave in and out of many different kinds of energy. Romantic honeymoon glows, periods of brooding, deep depression, anxiety, grieving and fear may be present at any time. The time is characterized by great emotional vulnerability and is a time when major life decisions are best avoided. National Acupuncture Detoxification Association © NADA 2008 Training Manual Section V: Integration 69 In “Twelve Step” time it is the period of working the first three steps, which involve ego dissolution, dethroning the king and discovering the meaning of the words powerlessness, humility, surrender and gratitude. It is also a period of self-forgiveness. This is not a static event, but rather a dynamic process. Patients must also deal with the disappointment that God has not rewarded abstinence with “instant wellness”. This period lasts about eighteen months following abstinence. One of the more harmful things we can do is to make an inflexible blueprint of this period. Give people “markers”; assure them that they are “right on schedule,” that it will get better if they don’t use. Making an issue out of these time zones and “phases” is dangerous. Counter transference – a projecting of our own hopes, fears, and expectations upon the client who will then think they are doing something wrong because they think that, “by now, they should be feeling thus and so.” Honor and support this recovery process on every level. Validation of experience is essential. “We are not bad people trying to become good; we are sick people trying to become well.” Also, “we are not victims of addiction, but survivors of our life experiences.” Acupuncture fills the experience-based gaps that exist in traditional treatment. It has the ability to offer a fundamental validation of experience and the possibility of healing. It is physically supportive, predictable, non-judgmental and validating. The client can access the experience on his or her own emotional schedule. One of the reasons that acupuncture needs to be daily, consistently, on demand, through the transition phase, is so that the client may come into the clinic for treatment regardless of how they feel that day, without fear of being judged, or of being asked to become cognitively engaged in a conversation about how they are doing. This is “barrier-free” treatment. It is after the completion of this transition phase that the full-body acupuncturist, at the client’s request, may begin to provide more expansive treatment. It is essential that the basic acudetox treatment continue to be available daily on demand so that the program can be malleable to the client’s unique and changing needs, rather than becoming dependent upon diagnosis for its success. This is a new experience for the client, and for the drug treatment establishment in charge of program evaluation. It is not new to the Twelve Step group, which says to the newcomer, “it works if you work it.” Ideally, there will also be crisis, referral or group counseling available “on demand.” Counseling should mimic the acudetox, in being supportive, non-judgmental, and validating of experience. National Acupuncture Detoxification Association © NADA 2008 Training Manual Section V: Integration 70 Caution should be taken not to expand prematurely into other emotional, social, and psychological issues. Eventually the client should become more and more centered in the Twelve Step recovery program and weaned from the treatment program. This often occurs naturally. The treatment program is never a replacement for recovery. An essential part of a good program is the design and planning of structures that serve as supportive “bridges” out of the program and back into the client’s community. STABILIZATION PHASE This phase commences with the onset of longer and longer moments of time in which the individual is a last comfortable inside their skin with the idea of non-use of psychoactive drugs. Typically this period begins with the client’s taking the 4th and 5th Steps and extends for three to five years into recovery. There has been surrender. In the stabilization phase, clients may sporadically return to the acupuncture clinic for “tuneups.” Secondary or “unmasked” symptoms and conditions will begin to be addressed. Major career and relationship decisions are often made. The sense of commitment to sobriety and sense of confidence that one is at last “out of the woods” however makes the risk of relapse during this period high. Acudetox continues to have a vital role, as well as the inclusion of therapy by other professionals, particularly those involved with body work. Nutritional needs will begin to be addressed. Secondary issues become primary – nicotine, eating disorders, sex addiction, or relationship addiction. Psychotherapy may begin to play a role as the client becomes ready to address family of origin issues. The family also may become involved in treatment. Unresolved issues, untreated, may precipitate relapse. Women’s’, Men’s and People of Color type issues also will surface and need to be dealt with in an empowering manner. Clients will shift addictions along the way – to political, spiritual, or gender movements – a new “fix” “out there.” If they are well supported enough to return again and again to their own center, they may learn the way to true empowerment. They may come to appreciate that the “path of excess leads to the palace of wisdom.” EMPOWERMENT This is the third phase of recovery. There are many “stuck points” in the shift from stabilization to empowerment. It is the acceptance of ourselves for just exactly who we are. It is difficult, also, in that every area of our society is saying the opposite, that we need to perform better, act better, accomplish more, acquire more control, more resources and energy, look better, get our lives together, set goals, lose weight, and aspire to be somebody at last. These are all things for which all referents are outside. Recovery doesn’t work in a vacuum. It occurs in the daily and moment-to-moment interface with the addictive systems in which we must function. We are vulnerable to being seduced back National Acupuncture Detoxification Association © NADA 2008 Training Manual Section V: Integration 71 into our addiction on a thousand levels – in every relationship, in every new memory of earlier pain, in every enterprise, in every unmet childhood desire, etc. It is not enough simply to be attending meetings, getting acudetox, having a sponsor, and abstaining from psychoactive drugs and addictive behaviors. We must live in our recovery, in our growth, in empowerment. Based on Transformation and Recovery, by Alex Brumbaugh, Santa Barbara: Stillpoint Press, 1994 See Acudetox and the Serenity Prayer, by Shellie Goldstein (Appendix “H 4”) National Acupuncture Detoxification Association © NADA 2008 Long-Term Program Sustainability Training Manual Section V: Integration 72 By Alex Brumbaugh The most important issues in acupuncture-based programs being sustained over time are maintaining the foundation of the program while at the same time remaining flexible and responsive to treatment and funding trends. Foundation Maintenance: Foundations are, by their nature, often beneath conscious awareness and attention. If a house has a good and strong foundation, people can live in the house and do things in the various rooms for many years and not be consciously aware of the foundation because it is “automatic,” or “built in.” Little ongoing attention needs to be paid to the good foundation of a house because houses are structurally static. Unless there are very severe external circumstances – such as termites, earthquakes or floods – these foundations require a minimum of maintenance. Treatment and recovery programs are structurally dynamic rather than static because of constant shifts in staff, client base, and funding. The influx of new staff, new philosophies, and new funding imperatives requires that sustained attention be paid to the foundation of the program. The architect Frank Lloyd Wright developed the concept of a cantilever foundation for tall buildings. Intended to make the buildings earthquake-resistant, a steel cantilever was driven deep in the ground, and from its vertical projection the building was suspended like branches from the trunk of a tree. Walls no longer had to depend upon corner beam supports, therefore freeing space for creative design. Wright believed that if the cantilever foundation went deep enough into the earth, there was no limit on how tall the building could be. If an earthquake came, the supple building would bend and sway like a tree in the wind but would never break. NADA treatment programs, in their traditions and spirit, are safe; accessible; welcoming; barrierfree; “user-friendly,” and client-centered. These organizing principles serve the program as the cantilever foundation serves a tall building. If these things are firmly in place and deeply honored, the program can easily withstand outside influences and dramatic changes in funding and staffing. Sometimes we become so accustomed to hearing about these foundation principles that they become clichés or hollow phrases, and their meaning can be forgotten or taken for granted. “Safe” means that it is okay for the client to be there. Some programs even have guards at the doors to assure the safety inside. The program serves as an oasis or safe haven in contrast to the environment in which the addict has to function outside. “Accessible” has meaning in terms of geographical location, and programs can better serve clients if they operate in the neighborhoods where the clients live, but it also means that the program is emotionally and psychologically accessible. There is no discrimination or judgment made about clients based upon class, race, gender, sexual orientation, or ethnicity. Nor is there discrimination based upon the particular circumstances that brought the client to treatment. The National Acupuncture Detoxification Association © NADA 2008 Training Manual Section V: Integration 73 fact that the client is involved in the criminal justice system, for example, is quite incidental to the client’s being an addict or alcoholic. “Welcoming” means that the program is as interested in common decency toward individuals as it is in therapeutic outcome. The client is respected as if a guest in ones home or a customer in ones store. In homes that are welcoming, and in stores that are successful, the guest/customer is “always right,” and the host is honored and graced by the guest’s or customer’s presence. Addiction is a disease of isolation, of being “outside.” A proper and genuine welcome into the recovery circle is so important that, for many clients, it may be all that is required for success! “Barrier-free” means that there are no “hoops” to jump through or interviews or assessments that the client needs to endure before something significant happens. The barrier-free acupuncture clinic as a “front-end” service provides this. “User-friendly” means that the program is relapse tolerant. It understands that the nature of addiction is that people use drugs. Programs that have daily urine testing have a distinct advantage in this regard. For programs that don’t, each counselor and acupuncturist must be in the ongoing process of examining their own reaction to a client’s use episode. The important thing is not that the client used, but that they came back. “Client-centered” means that the client is free to negotiate stabilization in their recovery on their own schedule rather than on the program’s schedule. It means that clients are met where they are and not where the program thinks they should be. Acceptance is the hallmark of recovery, and a program’s capacity to accept clients exactly where they are and to respond intelligently to that gives the program an opportunity to model recovery. A program that embraces these as the organizing principles of its deep foundation will be very likely to sustain itself and grow. There are three other intrinsic features of the NADA acupuncture modality itself that make it a foundation for other services, and it is important to program sustainability that these be kept in the consciousness of the program’s clinical and administrative staff. In preface to describing these three elements, a question we might ask is, “what can we possibly do in the design of our services to make them ‘competitive’ with the things we are asking our clients to give up?” In other words, what can we offer in the structure of what we do that can compete with, or replicate in a positive way, or mirror the things that our clients are doing outside at a level that will attract their attention, engage them, and retain them long enough for something significant to happen? Retention, as will be discussed in more detail below, is the central and most important concern of all chemical dependency treatment. We know anecdotally, and through research and outcome studies, that if we can retain clients in treatment long enough for something significant to happen for them, then they have a chance of achieving and maintaining recovery. If we cannot, their chances of achieving and maintaining recovery are very slight. Some programs offer psychoactive drugs as “replacement therapy,” and this helps achieve the goal of attracting the attention of clients, of engaging them, and of retaining them. Indeed, the National Acupuncture Detoxification Association © NADA 2008 Training Manual Section V: Integration 74 literature of drug treatment is largely a discussion of drug therapies, and these therapies, such as methadone, do in fact have the ability to compete with, replicate, or mirror some of the things that clients are expected to give up. Methadone programs have reasonable retention rates. But programs that elect not to rely on drug replacement therapy must rely on other services to achieve these goals. The most obvious service used in conventional programs is “talk therapy.” There are many different modes of talk therapy. Perhaps the most potent mode in early recovery is “disclosure” or peer support, which is the primary therapeutic mechanism of 12-Step programs. Some counselors who are themselves in recovery use this mode, and some programs use peer counselor and support groups. Education is another classic talk therapy mode in chemical dependency treatment, giving disease and about drugs, self esteem, family dynamics, and so forth. Another powerful mode is relapse prevention, providing the client with skills and tools to avoid the stresses that precipitate relapse. Another is case management, which is the often essential process of connecting the client with ancillary services. Finally, there is individual or family counseling or psychotherapy, which is generally essential in long term recovery. None of these diverse modes should be disparaged or discounted. They are vital and diverse, as the rooms in a house. They are the point of having a foundation. It is in these various modes that the “something significant” can happen that makes long term recovery possible. And yet these modes do not contain, either singly or collectively, the inherent deep structure that are necessary to have consistent success in attracting the attention of clients, of engaging them, and of retaining them for reasons we will describe. There are three ways in which the acupuncture modality provides these deep structures. 1. Acupuncture provides consistency. The first foundation element of the acupuncture modality is its unique ability to provide consistency. Chronic alcoholics and drug addicts crave consistency. This may seem a paradox in that their lives are generally characterized by inconsistency and unpredictability, but this is the very reason that they crave consistent experience. They seek and find this consistency in their drugs. Often, their drugs and the mental and emotional states they elicit are the only consistent thing in their lives. In the beginning of their use, they were perhaps motivated by noveltyseeking, but in the later or chronic stages they are far more interested in consistency, which is evidenced by how particular and meticulous alcoholics and addicts generally are about the brand, supply, dose, and strength of their drug(s), their synergistic effects, and so forth. A primary reason for this is that the motivation to take drugs in the chronic stage is in the amelioration of the symptoms of acute withdrawal. Chronic drug users are going through detoxification every day, whether they are in treatment or not, and they are engaged in the daily, methodical, and formidable task of masking and suppressing the discomfort of the symptoms of acute withdrawal with more drugs. This requires a fairly high degree of precision, attention, and consistency in dose-response. National Acupuncture Detoxification Association © NADA 2008 Training Manual Section V: Integration 75 The acupuncture modality we use has the ability to provide this consistency of experience and hence to replicate or mirror in a healthy way an important element of what we are asking them to give up. The talk therapies that programs provide, as rich and diverse as they may be, cannot provide this level of consistency since they are dependent to one degree or another upon the personality and skill and style and even the mood of the person delivering the service. The treatment effects of ear acupuncture, on the other hand, are relatively predictable and consistent independent of the acupuncturist who is delivering the treatment. The treatment is generic, and does not vary significantly based upon presenting symptoms or diagnosis. While the technique and strategy of choosing ear point location may vary slightly among different acupuncturists, the treatment experience is largely comparable to the last treatment, to the one before that, and so on. This consistency is supported by offering the treatment at the same time every day. This element provides a horizontal flexibility parallel to a 12-Step meeting, from which a participant can gain a predictable benefit regardless of the stage or phase of recovery that they happen to be in, and it is a benefit that is independent of the personality of the therapist. 2. Acupuncture works in the present moment. Most alcoholics and drug addicts are oriented toward living in the present moment. It is usually difficult for them to realistically project the consequences of actions into the future, or to relate present circumstances as being a consequence of past actions. The past in general is too painful to entertain, and while many alcoholics or addicts may have frequent reverie or fantasy about the future, they are usually not oriented toward realistic planning for the future. This is one reason why the 12-Step cliché of “one day at a time” is fairly easy for alcoholics and addicts to identify with. Psychoactive drugs operate in the present moment. It is for relief in the present moment that alcoholics and addicts ingest drugs. While psychotherapy seeks to operate in the present moment through accessing current feelings, much talk therapy in the stabilization phase of recovery – the first six months – is limited to the past and the future. Examples are, “How old were you when you first started using drugs?” or “How did it make you feel when that happened?” or “Can you think of some things you might do differently if that situation happens again?” etc. For people to be able to function in relation to past and future, they need to have the capacity to be in the present. If they have no comfortable “place to stand” in their present experience, they are not likely to be able to work constructively with past or future issues. Acupuncture operates in the present moment. It does not operate on a linear or horizontal plane, but on a vertical one, directing the attention inward toward the sources of healing. Michael Smith has stated that the goal of this therapy is not that people get well, which is unrealistic, but that they get better. In other words, while it is not likely that the acupuncture will alleviate all of the symptoms of acute or post acute withdrawal that the person is experiencing, it may give them enough hope and strength to make that discomfort endurable. If successful, they will reduce use National Acupuncture Detoxification Association © NADA 2008 Training Manual Section V: Integration 76 and return tomorrow. Because, if we can offer them something that makes them feel better in the present moment without drugs, we will have given them something that they may not have experienced in many months or even years, and this is something to which they are likely to return. 3. Acupuncture is a ritual experience. Addictive drug use is an experience surrounded by ritual. Each drug has its own culture and its own rituals that govern the procurement, preparation, and ingestion of the substance and the paraphernalia that is used. If one speaks with a newly recovered alcoholic or addict, one might even conclude that the person is as “hooked” on the rituals attending the use of the drug as they are on the effects of the chemical itself. Much relapse prevention work is indeed directed toward the rituals surrounding drug use that become, in recovery, relapse triggers – the “people, places and things” associated with the use of the drug. One function of rituals is that they give meaning to life, and we live in a culture that is lacking in ritual experience. Indeed, one of the reasons that people, especially young people, may be so attracted to addictive or “drug” cultures is the element of ritual or “life meaning” that attends these cultures. When an individual is faced with the prospect of giving up addictive drug use, they are also faced with giving up the attending rituals with which they may have formed a primary identification. Effective treatment must be structured to help provide ritual alternatives to compensate for this loss. 12-Step programs achieve this compensation for many people. Attending a 12-Step meeting is a ritual experience. The meeting always begins and ends, without deviation, with the same words spoken and the same formalities. The words spoken at the opening of the meeting are an invocation for what is to follow. The invocation creates, within the meeting, ritual space in which healing can occur. Indeed, another principle function of ritual is to invoke an opportunity or “space” for healing, for transformation, or for spiritual experience. Coming for acupuncture is a ritual experience. The tea is part of this. More important is the design of having the client do for themselves everything that they possibly can, such as signing in, getting their won treatment card, selecting their needles, opening the packet, prepping their ears, and taking their own needles out at a mirror following treatment. As one can readily observe in the acupuncture clinic, all of these things are quickly learned, adapted, and seriously undertaken by the client as a part of a recognized ritual. And, as is the case with the 12-Step meeting, these repetitious behaviors invoke the “content” of the treatment experience which, again, gently directs the attention away from external or linear matters and inward toward the sources of healing and transformation. In these three ways, the deep structure of our acupuncture treatment modality has elements that help attract the attention of clients, engage them, and retain them in treatment. It therefore provides a foundation of recovery that greatly enhances and enriches the other diverse modes of service that programs offer. It provides clients with something recognizable, personal, meaningful, and consistent to which they can return at any time regardless of how they are doing in other areas of their lives or in other parts of the program. National Acupuncture Detoxification Association © NADA 2008 Training Manual Section V: Integration 77 All of these foundation elements of NADA programs can be threatened in at least three ways: 1. In busy clinics, over time the acupuncture can tend to “disappear” from consciousness and be taken for granted. If administrators, counselors and other staff begin to take the acupuncture service for granted and fail to provide support for the acupuncturist during clinic, the ambiance of the clinic can rapidly deteriorate. The acupuncturist requires the support of at least one other dedicated counselor or clinic monitor for every ten clients to assist with sign-in, intakes, safety issues, tea, noise level, and the emergent concerns of clients. The ratio of one acupuncturist to 24 clients in an hour should also be diligently followed. 2. If the program places a condition on clients receiving acupuncture, such as participating in groups or other treatment services, then the treatment is no longer barrier-free, and clients who are not emotionally ready for other program services will generally drop-out. One of the cardinal strengths of acupuncture is in making treatment accessible, and any conditions the program places on the service threatens this accessibility. Programs may be tempted to do this because of funding or billing imperatives, or because they are impatient with the length of time it may take some clients to begin to access other more cognitive treatment components. 3. If the acupuncturist enters a diagnostic relationship with the client prematurely and expands the 5-point auricular protocol, some of the deep structures that make acupuncture the foundation are compromised. • The treatment is no longer consistent, and now depends upon verbally engaging the client in diagnostic transactions. If good benefit is achieved, the client may return the following day expecting similar results, which may not be realistic. A relationship and hence bonding will occur in the diagnostic process between the client and the individual acupuncturists, creating the opportunity for dependence of the client upon the therapist for sustaining his or her recovery rather than upon a therapeutic process guiding him to inner resources. This can be especially disruptive if the program employs several acupuncturists. While experientially, the treatment itself will still function in the present moment, the diagnosis that precedes the treatment will require accurate historical information on the part of the client, shifting the therapeutic process from vertical to linear transactions. And, while the skilled acupuncturist may develop the level of trust necessary for accurate diagnosis, that trust depends upon interpersonal verbal exchange, and the systemic value of a non-verbal treatment opportunity is lost. It is important to realize in this regard that for the newly sober client, relapse is a “statistical inevitability,” and the clinician must evaluate the impact of individualizing treatment upon potential relapse and, most important, upon the client’s psychological ability to return to treatment following a use episode. Finally, the ritual associated with the repetitive auricular acupuncture experience has been lost. Even though the treatment itself may invoke ritual healing space for the • • • National Acupuncture Detoxification Association © NADA 2008 Training Manual Section V: Integration 78 client, addicts are a neurologically and emotionally sensitive population, and “simple is better” until stabilization is achieved. A safe, predictable, and simple container for ritual experience is better in the beginning as a balanced response to the paradoxical presentation of both Excess and Deficiency in chemical dependency clients. Flexibility and Responsiveness to Funding Trends Once these foundations are secure in the awareness of program staff, the program can be creative and flexible with other program elements. It can add things, trim things, experiment with on-site vocational rehab or innovative mental health programs, enter collaborative relationships with disparate agencies, expand into new client arenas, add smoking cessation programs, and so forth. Nothing in the chemical dependency field seems static at the present time. There are dramatic shifts in the channels through which funding happens. Future funding is apt to arrive less through conventional channels and more through departments of education, housing, criminal justice, and social services. Each of these venues requires that the program be able to “speak different languages” to respond to different perceptions of need. A competent and sustained program will be able to interface as effectively with school superintendents as with public health officials, or with probation officers as with the welfare case manager. Leaders in the program are challenged to cultivate the breadth of understanding and flexibility necessary to respond to these shifts without losing the deep foundation of what their program does. Survival in the current funding environment also challenges us to be able to translate what we do into verifiable treatment outcomes and milestones. As funding shifts, so do outcomes and milestones. For one funder, employability is the significant outcome; for another it is housing; for another it is a reduction in crisis mental health services, or better grades in school, or a reduction in criminal behavior. We need to be able to track client progress along a multitude of lines while at the same time politely educating funders that, for addicts, all of these domains are secondary to sustained sobriety. While we know that people who achieve and sustain sobriety invariably seek improved vocation, permanent housing, utilize fewer public services, and so on, we need to improve our skill at tracking these secondary benefits in objectively verifiable ways. Acupuncture lends itself well to the new outcome funding environment, particularly in the critical stabilization phase of recovery. The premier cause of relapse and treatment drop-out is the program’s failure to adequately address the physical symptoms of acute and post acute withdrawal. Many conventional treatment programs have no therapies in place at all to respond to these physical symptoms. A program’s rich array of educational, counseling, and case management services and comprehensive video library will be of little avail if the client is experiencing a cycle of acute craving and anxiety. Programs that cannot retain clients in treatment during the early relapsing phase will not have good long-term outcomes, and the key to that retention is the program’s ability to respond to these inevitable and persistent physical symptoms. Therefore, a fundamental stabilization milestone is that “the client self-reports relief from the symptoms of acute and post-acute withdrawal.” It can be easily shown through client tracking that success in this milestone correlates with success in the subsequent milestone of program retention: “client remains in treatment at (30/60/90) days and continues to comply with treatment National Acupuncture Detoxification Association © NADA 2008 Training Manual Section V: Integration 79 plan.” And, the one thing we know for certain from chemical dependency research is that the longer the client can be retained in treatment, the better the long-term outcomes, whether primary or secondary. The only method besides acupuncture for achieving this first critical milestone is drug therapy. Indeed, drug applications such as buprenorphine for opiates, Prozac (buproprion) or generic imiprimine for cocaine and amphetamines, and Naltrexone or phenobarbital for alcohol, are gaining increased acceptance in outpatient programs. This approach requires medical supervision, however, which adds dramatically to the cost of services. Acupuncture-based programs, therefore, who have cultivated the capacity to track these milestones, are wellpositioned to compete in this new outcome-funding environment. National Acupuncture Detoxification Association © NADA 2008 Acudetox and the Mutually Supportive Peer Fellowships. Training Manual Section V: Integration 80 Since the initial days at Lincoln, NADA has always encouraged acudetox clients to engage in mutual support fellowships. Treatment, even acudetox-based treatment, represents a finite intervention, while recovery from addictions represents a life-long process of growth and transformation. As always, NADA recognizes that acudetox is not a stand-alone treatment. Active engagement with a community support system increases the likelihood of long-term sobriety. There are many different support fellowships. Different communities have different offerings and clients will have to find the groups whose philosophy, content, and style best suit their needs. The important components are accessibility, availability, relevance and accountability. Almost all communities around the world have fellowships patterned after the 12 step model developed by Alcoholics Anonymous (AA). AA offers not only a rich and ready support system but also an outlined path for living, the 12 steps. Other 12-step groups include, Narcotics Anonymous, Nicotine Anonymous, Al-Anon, Nar-Anon (for persons associated with alcoholics and addicts respectively), Co-Dependents Anonymous, Overeaters Anonymous, Gamblers Anonymous, Sex and Love Addicts Anonymous, Workaholics Anonymous, etc. Other, non-12 step examples of support groups exist, such as Rational Recovery. Alcoholics Anonymous: “Alcoholics Anonymous® is a fellowship of men and women who share their experience, strength and hope with each other that they may solve their common problem and help others to recover from alcoholism. The only requirement for membership is a desire to stop drinking. There are no dues or fees for AA membership; we are self-supporting through our own contributions. AA is not allied with any sect, denomination, politics, organization or institution; does not wish to engage in any controversy, neither endorses nor opposes any causes. Our primary purpose is to stay sober and help other alcoholics to achieve sobriety.” Copyright © by The A.A. Grapevine, Inc. www.alcoholics-anonymous.org National Acupuncture Detoxification Association © NADA 2008 The 12-Steps Training Manual Section V: Integration 81 While the concept of the twelve-steps began with Alcoholics Anonymous, most fellowship groups for addicted populations have adapted these tenants for the specific addictions. The following are the steps for addictions in general: 1. 2. 3. 4. 5. 6. 7. 8. 9. We admitted that we were powerless over addiction, that our lives had become unmanageable. We came to believe that a Power greater than ourselves could restore us to sanity. We made a decision to turn our will and our lives over to the care of God, as we understood Him. We made a searching and fearless moral inventory of ourselves. We admitted to God, to ourselves, and to another human being the exact nature of our wrongs. We were entirely ready to have God remove all these defects of character. We humbly asked Him to remove our shortcomings. We made a list of all persons we had harmed, and became willing to make amends to them all. We made direct amends to such people wherever possible, except when to do so would injure them or others. 10. We continued to take personal inventory and when we were wrong promptly admitted it. 11. We sought through prayer and meditation to improve our conscious contact with God, as we understood Him, praying only for knowledge of His will for us and the power to carry that out. 12. Having had a spiritual awakening as a result of these steps, we tried to carry this message to addicts, and to practice these principles in all our affairs. See Appendix “H 3” for more information on AA. National Acupuncture Detoxification Association © NADA 2008 Training Manual Section V: Integration 82 National Acupuncture Detoxification Association Training Manual © NADA 2008 Section VI: Oriental Medicine and Behavioral Health 83 Oriental Medicine in the Context of Addictions and Behavioral Health Treatment Introduction to Oriental Medical Concepts Oriental Medicine as Related to Behavioral Health and Recovery “Empty Fire” Some people have found the following to be accessible introductory texts: The Web That Has No Weaver, by Ted Kaptchuk, Between Heaven and Earth, by Harriet Beinfield and Efrem Korngold, and Voices of Qi – An Introductory Guide to Traditional Chinese Medicine, by Alex Holland. National Acupuncture Detoxification Association Training Manual © NADA 2008 Section VI: Oriental Medicine and Behavioral Health 84 National Acupuncture Detoxification Association Training Manual © NADA 2008 Section VI: Oriental Medicine and Behavioral Health 85 Oriental Medical Concepts Qi Most ancient healing arts understood that all living things were greater than the sum of their parts and one of the key components that supports this understanding is the concept of ki, prana or elan vital. In Oriental medicine this intangible substance is known as qi or chi (pronounced “chee”) and can be viewed as the intangible part of the person that empowers the being and makes each individual unique. Oriental thought also does not separate the person into body, mind and spirit but rather considers the person in his or her entirety or wholeness. The ancient texts describe many types of qi and state that the different forms travel within or along pathways known as meridians. Some of these pathways connect with the organs that are themselves described in physical, emotional and spiritual terms. For example the heart, while in modern medicine is seen as solely as a blood pump, in Oriental medicine is said to be the seat of the person’s mind and home of his or her spirit. Qi is sometimes referred to in terms of what it does. For example, wei (pronounced “way”) qi resides just below the skin and is often termed “protective qi”. The qi we receive from the food we eat, termed gu qi, is often translated as nutritive qi. Qi is also responsible for giving us the ability to be animated. However, qi is not what causes movement or powers movement because qi can’t be separated from the movement itself. Similarly, qi is what allows us to grow and mature and it is growth and maturity as well. Health and Disease In Oriental medicine health and disease are also manifestations of qi, or more accurately how the qi is traveling within and along the meridians. When a person’s qi is flowing smoothly and appropriately the person is said to be in a state of wellness. When the qi is obstructed or not what the person’s wholeness is needing, dis-ease occurs. Oriental medicine uses interventions – acupuncture, herbal medicine, tai chi, qi gong, nutritional and lifestyle recommendations, tui na (medical massage), etc. –to restore harmonious qi flow so that healing on all levels of the person’s being becomes possible. Yin and Yang One way of observing the manifestation of qi in a person is via yin-yang theory. This Oriental medical model of inhibiting and activating forces translates literally as the dark and light sides of a mountain. Yin and yang are considered opposite yet interacting relative realities and one cannot exist without the other. We only know that the side of the mountain on which the sun is shining is light because we have experienced darkness on the other side and vice versa. We understand these things in relationship with and relative to each other. Hot/cold, male/female, inside/outside, movement/stillness, health/disease, and addicted/recovered only exist because we know of the other opposite interrelated manifestation. National Acupuncture Detoxification Association Training Manual © NADA 2008 Section VI: Oriental Medicine and Behavioral Health 86 Everything in the universe has yin and yang components because everything in the universe exists in relationship to everything else. There are no absolutes. Things can be relatively more or less yin or more or less yang relative to something else. For example, compared to noon, dusk would be considered less yang (less light) while at the same time being relatively less yin than midnight (not as dark). On the other hand, dusk is also relatively more yang than midnight. It is also said that yin and yang transform into each other. As we go past midnight and continue into dawn, we see yin slowly transforming into relatively more yang. Likewise as noon becomes dusk and dusk is followed by evening we see yang transforming into a relatively more yin state. The same holds true with the seasons – winter to spring to summer to fall and back to winter – ever transforming into relative levels of yin and yang. The yin-yang or tai chi symbol embellishes all of these concepts in that we see the relatively lighter side, the relatively darker side as well as the mutual interdependence upon and transformation into each other. Note also the light and dark “eyes” within the maximal yin and yang components representing the fact that there is always a bit of yin in every yang and vice versa. Because the manifestation of qi in the body can be described in terms of yin and yang, it follows that wellness is dependent upon an appropriate balance of yin and yang and yin and yang-like activities. In general, yang has to do with movement and doing while yin is concerned with stillness and being (think back to the light and dark sides and the activities in nature these two states induce). Constantly being on the go or under “stress” (yang) without proper rest and nourishment (yin) undoubtedly will lead to disease due to imbalance. On the flip side, being a coach potato (yin) without getting out into the world (yang) can be just as detrimental to health because of the imbalance in the other directions. Yin versus Yang While all things exist in relation to each other, activities and states of being can generally be assigned as relatively more yang or relatively more yin. Following are examples of each state: National Acupuncture Detoxification Association Training Manual © NADA 2008 Section VI: Oriental Medicine and Behavioral Health 87 Yang Light Hot Full Male Scattered Heaven Upward External Outwards Lateral Fire The “High” Doing Active Forceful The Mind Expend Faster Energy Acute Disease Wakeful Reason Yin Dark Cold Empty Female Dense Earth Downward Internal Inwards Medial Fuel The Drug Being Passive Calm The Brain Accumulate Slower Matter Chronic Disease Sleepy Intuition The above list also indicates that anatomical directions also have yin and yang correspondences. Humans are considered the vessels between heaven and earth. Therefore, towards the head (superior anatomical direction) is considered yang relative to the feet (inferior direction) that are considered more yin. Towards the periphery of the body (lateral direction) is considered yang relative to the medial inner core of the body (relatively yin). Regarding the ear, the depressions (the fossa and concha areas) are considered yin relative to the raised surfaces since the depressions are closer towards the body’s core. Dark depressions are also relatively more yin than raised surfaces. Addictions/Behavioral Health and Empty Fire Modern culture is one that tends to be external and aggressive: yin fueled, yang-like activities such as intense stimulation, competition, caffeine consumption, etc. More importantly, little time is spent replenishing this lost yin leading to a condition known as yin xu (yin deficiency) that often results in mental restlessness, agitation, troubled sleep, and the like. While these manifestations appear to be due to excess yang, they are actually symptoms of the underlying phenomenon, the deficient yin in a condition NADA refers to as empty fire. In other words, while the person’s symptoms and behaviors appear to be from too much yang, the person is most likely deficient in both yin and yang. It is because the yin is much more depleted that the yang appears to be in excess. Without the solid, firm grounding the yin provides the yang-like symptoms flare up, thus the term empty fire. National Acupuncture Detoxification Association Training Manual © NADA 2008 Section VI: Oriental Medicine and Behavioral Health 88 Addiction, by its very nature, also consumes vast amounts of yin. In addition to that which is consumed by the substances and behaviors themselves (for example, cocaine or gambling), individuals challenged by their relationships with addictive substances generally live lives filled with violence and abuse and are in states of fear and denial. Without the yin to balance the yang, symptoms that appear to be from an excess of yang arise (aggression, anger, increased violence). Yang behavior is not the true problem, however but merely a symptom of the underlying deficiency. Not liking the effects, the individual then continually repeats his or her behaviors in an attempt to self medicate (e.g. drink more, rationalize, obsess, etc.) which further depletes yin and a dangerous spiral ensues. More substances or behaviors are required to provide the same level of comfort, a phenomenon known as tolerance in modern, Western medical terms. Often society tends to respond to these individuals with force and or control such as locking them up in jail or prison. Under force, he or she fights back, a yang-like activity, which further increases the disparity between yin and yang. Therefore the key to successful treatment for substance abuse lies in being able to nourish yin – to put a firm foundation back under the individual – both in the personal and social realms. Treatment should provide a means for the client to gain knowledge of his or her needs by providing the ability to have an internal experience. This internal experience will, in turn, build the internal structure many of these individuals lack so that his or her healing can take place on a firm foundation. There are many ways in which individuals can nourish their own yin but few people have the self-discipline to do so on their own, at least initially. Persons in early recovery generally lack the necessary ego-strength to practice meditation, yoga, tai chi or self-healing practices effectively. In essence they lack the initial inner strength to attain inner strength and often become frustrated at the lack of progress. It is imperative, therefore, that aspects of addictions and behavioral health treatment be yin nourishing. This is true of the environment, the interactions during treatment and the treatment itself. The NADA acudetox protocol provides a simple, minimally interactive modality that allows for internal experiences beyond those which clients can experience on their own. Acudetox uses the ear, associated in Oriental Medicine with the energetic Kidney, and specific yin points in the ear, the Heart (Shen Men), Kidney, Liver and Lung to contact, nourish and strengthen the yin as well a yin-like treatment experience. As the yin develops so will the client’s ability to go deeper inside. It is important not to minimize or distract the client from his or her right and need to experience painful feelings, an essential part of healing. Yin nurturing treatment includes holding the space for the client, providing structure and a safe environment while helping to foster a spirit of discovery and curiosity about feelings, thoughts and beliefs. Successful healing must begin at this deep, inner level. National Acupuncture Detoxification Association Training Manual © NADA 2008 Section VII: Client Management Issues & Strategies 89 Client Management Issues and Strategies Special Populations: Understanding Needs and the Role of Acudetox National Acupuncture Detoxification Association Training Manual © NADA 2008 Section VII: Client Management Issues & Strategies 90 National Acupuncture Detoxification Association Training Manual © NADA 2008 Section VII: Client Management Issues & Strategies 91 Specifically defined populations Programs find acudetox particularly helpful in meeting the special needs of groups such as adolescents, elderly, women, culturally defined populations, gay/lesbian/bisexual and transgender clients, criminal justice-involved clients, homeless and/or job-less clients, veterans and clients with co-existing disorders including HIV/AIDS, hepatitis, mental health concerns, chronic pain, domestic or other violence, and trauma survivors. These populations tend to have more trouble getting and staying clean due to additional complications and stigma. Generally, programs that target special populations offer clinical and/or medical interventions specifically designed to address the unique needs of that group. For example, adolescents in California reported that acudetox not only supported their recovery from alcohol and drug addictions, but also made it easier to study and focus in school. Clients with co-occurring HIV/AIDS and/or Hepatitis report better overall general health with acudetox. Programs often encourage or offer full body acupuncture and herbal medicine to address viral induced symptoms as well as medication induced symptoms. Acudetox and Women The number of women, including child-rearing and/ or pregnant clients, in addictions and behavioral health treatment programs has steadily increased. Women need treatment that addresses their particular needs as women, and can be arranged around their child-care responsibilities. Lack of safe childcare, as well as cultural barriers such as greater societal stigma around addictions, creates barriers to entering treatment. The stigma is really intensified for women who are pregnant. Some states have even gone so far as to prosecute or mandate treatment for women who use drugs while pregnant. Acudetox has proven to be a very effective intervention with this population, which is particularly significant because other, medication-based forms of treatment are not appropriate and/or available to pregnant women. The use of Acudetox led to a considerable expansion of treatment services for cocaine and crack using women. Perinatal programs ideally provide combined prenatal care, parenting skills education and support, along with addiction treatment. Lincoln Recovery Center has offered a specialized maternal program since 1987, and has been treating more than 100 pregnant cocaine users per year. Women bring their infants and small children to the clinic. Typically, the young mother will sit with a baby in her lap during the ear needling treatment. The Acudetox provides relaxation and reduction of stress. Frequent supportive counseling sessions replace the confrontations that are typical of some other drug-free programs. Mothers who must bring children or make child care arrangements often need flexible scheduling for counseling and other appointments. Lincoln clients have regular visits with a nurse-midwife and receive specific education and counseling relative to pregnancy and child-care. The Lincoln program was cited as a model innovative program for prenatal care in a monograph, "Hospital and Community Partnership" issued by the American Hospital Association in 1991. National Acupuncture Detoxification Association Training Manual © NADA 2008 Section VII: Client Management Issues & Strategies 92 The average birth weight for babies at Lincoln with more than 10 maternal visits is 6 pounds 10 ounces. The average birth weight for less than 10 visits is 4lbs 80z, which is typical of high-risk cocaine mothers. There is a high correlation between clean toxicologies, retention in the clinic program, and higher birth weights. 76% of pregnant women are retained in long-term treatment and give birth to non-toxic infants. Premature birth is a serious health risk. The Hospital of St. Raphael in New Haven has been using the Lincoln Acudetox model for many years. The director of obstetrics, Dr. Wilfredo Reguero, reported a drop in perinatal death rate from 18.5 to 7.1 from 1990 to 1992, following the use of the NADA protocol and other innovative outreach techniques. Special Acudetox-based components have also been developed for women with children in long term foster care in the Drug Strategies Institute program in Baltimore. There are a variety of other treatment settings around the country utilizing Acudetox in maternal programs across the full continuum of care. These include inpatient facilities and halfway houses that take women with their children, outpatient and day treatment programs. Particularly innovative is the BASICS program in Minneapolis/St. Paul, Minnesota that utilizes an Acudetox Specialist (ADS) as a member of multi-service treatment team providing home based services. Vital to the success of any maternal substance abuse program is helping the woman to become drug-free for herself, not just "for the sake of the baby". A person who appreciates her own value will be a better parent and is better able to refuse drugs and drug filled relationships. It is also important for the program to understand the woman as more than a "fetal container" and therefore not abruptly terminate services after delivery. Most addicted women also bring to treatment their experiences of trauma including violence, sexual abuse, rape, etc. Female clients are often trapped in destructive and exploitative relationships and therefore may have special difficulty with any therapeutic relationship. A consistently tolerant and non-confrontational approach prepares the way to establish a trauma survivor support service for patients at an early sobriety stage of recovery. The supportive atmosphere makes it relatively easy for clients to keep children with them during treatment activities. The acupuncture point formula used for substance abuse is also specific for the kind of emotional and muscular guarding associated with early sexual trauma. These clients will suffer intermittent crises and experience profound challenges to their physical and spiritual identity. All of their relationships will be strained and transformed. Acudetox is very appropriate adjunct to trauma survivor's support work. There is some indication that women are most vulnerable to relapse in the luteal phase (the last 14 days) of their menstrual cycle. Some programs especially encourage women to return for relapse prevention acupuncture treatment around day 18 of their cycles. Some programs provide services for both adults and their children. The addition of acupressure beads for both adults and their children shows benefit. One example is the Tree of Life Chemical Dependency Treatment Program’s Pregnant/Parenting Women’s Recovery Program in Everett Washington. Anonymous comments from both parents and children are listed below: National Acupuncture Detoxification Association Training Manual © NADA 2008 Section VII: Client Management Issues & Strategies 93 “The pellets have helped tremendously. I have been able to stay focused and my mind has stopped spinning. My son has been able to stop being so wild. He has calmed down a hundred percent.” “I don’t crave or smell or taste my drug of choice. I am focusing on the program more than ever.” “I felt calmer at times when I probably would have been more stressed. I thought more clearly. It was also nice knowing that I had help at hands reach when my anxiety increases.” “My 13-year-old son had the pellets about a week ago. He had a pretty intense smoking habit as well as depression. He has not smoked for a week. His whole attitude has changed to happiness and well being. He helps people and he’s very thankful for everything.” See Appendix “F1” Behavioral Health Issues/Dual Diagnosis The reality of co-occurring disorders of mental illness and substance abuse, also known as “dual diagnosis”, and “mentally ill chemical abusers (MICA)”, has gained increasing attention. Some experts estimate that 60% of the addicted population has a co-existing mental disorder. Coexistent mental disorders commonly seen include: mood disorders (including bipolar affective disorder, depression, etc.) anxiety disorders, post traumatic stress disorder (PTSD) and other trauma-related conditions, dissociative disorders, psychosis and schizophrenia. Active substance abuse may exacerbate mental illness and may confound underlying psychiatric issues and interfere with treatment by masking, complicating, or mimicking psychiatric illness. Mood altering chemicals distort perception/thinking patterns and may affect psychotropic effectiveness as well as medication compliance. Therefore MICA individuals need both addiction treatment intervention and mental health treatment in order to succeed. Clinical experience has shown the NADA auricular acupuncture protocol to be very effective for individuals with co-existing mental and addictive disorders. Generally, clients with cooccurring mental health issues find acudetox decreases anxiety and depression. Programs document fewer incident reports such as episodes of violence and better compliance with medication protocols. Programs also report better compliance and fewer adverse reactions associated with their psychotropic medications. During the past 35 years at Lincoln Recovery numerous effects of acudetox on patients with coexisting addiction and psychiatric conditions have been observed. Agitated patients routinely fall asleep while receiving acupuncture. Chronic paranoid patients have a higher than average retention rate. Lincoln Recovery Center recounts many examples in which grossly paranoid addicted persons have made special efforts to access acudetox treatment, not projecting paranoid ideation on the treatment, even though they may be floridly psychotic otherwise. National Acupuncture Detoxification Association Training Manual © NADA 2008 Section VII: Client Management Issues & Strategies 94 These patients experience a gradual reduction in psychiatric symptoms as well as a typical response in terms of craving and withdrawal symptoms. Psychotropic medication does not interact with acudetox. Patients should remain on psychotropic medicines while using acudetox, since the improved level of compliance which correlates with acudetox often makes the process of medication more reliable and effective. Harbor House, a residential program for mentally ill chemical abusers (MICA) in the Bronx, reported a 50% reduction in psychiatric hospitalization in the first year of acudetox utilization. Their drop out rate during the first month of treatment decreased 85% during the same period of time. Dually diagnosed patients in an inpatient, state hospital-based program in Pueblo, CO who chose to receive NADA-style acudetox as part of their treatment were twice as likely to complete the 90 day program successfully as compared to patients who did not use acudetox, as reported in 2006. Acudetox has an obvious advantage in the treatment of MICA clients, because it can be used for a wide variety of addictive and psychiatric problems. MICA clients have particular difficulty with bonding and verbal relationships. Acudetox facilitates the required lenient supportive process, but, at the same time, it provides an acute anti-craving treatment which is also necessary. The use of acudetox can resolve the contradictory needs of MICA patients. More work needs to be done to evaluate and understand this anecdotal data. The Waco, TX Experience: A pilot program used acupuncture according to the Lincoln model in the public mental health system in Waco, Texas with a goal of reducing nicotine use. Highly disturbed, non-compliant, chronic dual diagnosed patients were deliberately selected for this trial. Nicotine use decreased or ceased and rates of hospitalization dropped from 50% to 6% in the group of 15 patients. The patient group was considered to be the most chronically ill and most likely to return to mental hospitals or jail. They often “self-medicated” through the use of nicotine, alcohol, street drugs and other substances of abuse in an attempt to relieve the acute symptoms of their disease. Their need for services ranged from a requirement of 24 hour care to that of intermittent case management services coordination. Services included social, medical, psychiatric and psychotherapeutic interventions. Acudetox was introduced to the population because the clients in this case-management group were spending 60% of the SSI income on cigarettes. The nicotine addiction caused financial problems, interpersonal difficulties with peers, family and staff, stealing, and prostituting themselves in order to get cigarettes. Traditional treatment approaches had proven ineffective. Case management staff instituted the use of the NADA protocol. Soon after the ear acupuncture treatments began unanticipated effects were noted by staff, clients and family members. These included better sleep, reduced stress, a sense of greater relaxation, improved appetite, increased sense of purpose, clearer mind and more energy. Over time, staff noted that National Acupuncture Detoxification Association Training Manual © NADA 2008 Section VII: Client Management Issues & Strategies 95 the number of hospital admissions for the clients decreased dramatically from the average number of admissions for the previous three years. Clients of the program were also noted to be more accessible to traditional treatment methodologies. They were easier to engage interpersonally. Medically related physical changes were noted, including reduction of high blood pressure and increases in low blood pressure into normal ranges. The NADA protocol did not reduce the necessity for psychotropic drugs, the need for case management or psychotherapeutic interventions, but different types of services had to be developed. More psychosocial activities, including skills development and the practice of using the new skills became essential in helping patients handle their new found level of functioning. Staff was forced to shift their work styles and program offerings to meet client requests. Staff noticed that their caseload clients were more demanding of services. However, the staff soon discovered the changes created a more interesting program environment. Clients requested the formation of a patient government. They wanted more challenging programming. They were able to welcome newcomers into the environment more easily. They wanted to take field trips. These requests were quite different to deal with programmatically, than the more medicated and somnolent atmosphere that had existed before the acudetox was implemented. There was clearly more “aliveness” among the clients, and staff soon learned to enjoy the interests and vitality that clients displayed. Unfortunately, acudetox was discontinued for this population. Hospital admissions and violent incident rates which had dropped to zero during acudetox implementation, gradually reverted to original levels. Acupressure Beads for Attention Deficit/ Attention Deficit Hyperactive Disorder Attention Deficit Disorder and Attention Deficit/Hyperactive Disorder are both serious conditions affecting thousands of individuals and families. Modern medicine has little to offer except medications with serious side effects. In 1997 Lincoln Recovery began expanding the clinical horizon to include the treatment of ADD/ADHD on a pilot basis. Technique: An acupressure bead, easily applied to the surface of the ear by adhesive tape, is fixed to the posterior surface of the external ear just opposite the location of the “Shenmen” point on the anterior surface. The location is generally above the superior end of the “depressive groove”, a physical demarcation on the posterior ear. Often there are observable indicators of the point location on the surface of the ear. These indicators are typically one or a combination of the following: distended veins, moderate erythemia, poor skin tone or visible indentations on the surface of the ear at that location. There is often a clear sensation of Qi when the bead is applied. The beads are kept in place continuously, and replaced when the adhesive tape becomes worn. Generally gold beads have found to be most effective, however, some children respond better to the silver beads. In Oriental medicine, gold is considered to be strengthening/tonifying and silver is considered to be balancing/calming. Staff in some programs notice that clients are generally attracted to the metal that provides them the best benefit. Allowing clients to choose between gold and silver is an easy way to assess which National Acupuncture Detoxification Association Training Manual © NADA 2008 Section VII: Client Management Issues & Strategies 96 metal best suits the individual. When in doubt, the energetically neutral vaccaria seeds may be used. The technique is easily taught, and even family members can learn to place the bead, for simple maintenance of the protocol. Medication changes are not suggested without the recommendation of the primary prescribing physician on the basis of clear changes in the clinical picture. The following are anecdotal examples: 1. D.B. was placed on Ritalin 30 mg/day at age 4. He was an angry child, destroying anything in his way, with an attention span of less than 5 seconds. On daytime medication D.B. sat unproductively most of the day. In the evenings he was restless, tearful and hyperactive. By age 14 D.B. was taking Dexedrine, Lithium and Catapres. His blood pressure was 150/90. He remained somnolent or hyperactive, unable to have a productive life on any dose of medication. His parents had tried numerous additional remedies to no avail. At age 14 (in 1996) D.B. responded immediately to his first ear acupuncture treatment. His sleep and activity patterns normalized within a week. His blood pressure and symptoms of depression subsided within weeks. Soon D.B. was using acupressure seeds and beads on a regular basis. His school performance improved steadily even as the Dexedrine was being discontinued. In 1998 D.B. participated in drivers education classes, participated in horseback riding, had a part-time job, mentored kindergarten children, and was able to study for hours at a time. He became a charming, relaxed young adult, quite aware of his educational deficits and sought to improve himself on a daily basis. D.B. is able to tell his mother when he needs to have follow-up acupressure bead treatment. 2. G.H., a five year old boy living in a therapeutic residence because of his mother’s clinical status. G.H. would stomp his feet frequently and required 7 “time outs” per day for social management. After one week of acupressure bead placement, G.H. could sit calmly and no longer required “time outs” for social control. His teacher said that he completed his homework and “now he learns so fast.” The beads “make me happy” G.H. says. 3. D.K. was abandoned at the age of 2 and entered foster care. He was developmentally delayed and placed on Ritalin and Ativan. At age 12 (1998) D.K. was living with his aunt and doing poorly even in special education classes. After the acupressure beads were applied in May of 1998 D.K. was able to focus in school and his bouts of anger decreased. Soon D.K. began to talk about his mother in a hopeful manner. He visited her each weekend over the summer and later was able to live with her in a constructive manner. D.K. no longer takes medication and is able to ask for acupressure beads whenever he feels it is necessary. Most of the ADD/ADHD children have responded favorably to this treatment within the first week of bead placement. Their response seems independent of the family’s motivation or other psychosocial variations. Treatment effects seem to be unrelated to the use of medication. These reports are preliminary anecdotal findings. However, it is encouraging to see apparently unmanageable chronic patients respond favorably to a safe inexpensive treatment. National Acupuncture Detoxification Association Training Manual © NADA 2008 Section VII: Client Management Issues & Strategies 97 Andrea Andrea is a 14 year old girl who lives in an institution. She has Downs Syndrome, nystagmus, as well as what the institution staff terms “nervous disorders”, including attention deficit disorder. Periodically, the program has the children draw self-portraits. Here is Andrea’s attempt at drawing herself. Some of the views have multiple eyes, some only one. There seem to be barbs around her head. In viewing her drawings it would seem that Andrea’s head is not a very pleasant place to be. Because of her nystagmus, Andrea has difficulty walking down stairs. She must hold onto the railing and step with one foot, and then the other. Then she moves her hands down a little farther and begins the process again on the next step. She has few friends in the program. There is not much in this young girl’s life that looks easy or comfortable. Andrea, before beads October, 1999 National Acupuncture Detoxification Association Training Manual © NADA 2008 Section VII: Client Management Issues & Strategies 98 The inquiry was made of the staff at the institution where she lives; no one knew how long Andrea had been there, where her parents were or even if she had parents. At some point in Andrea’s life she was institutionalized, but there is not much information beyond that. About five months later, the activity of self-portraiture came up again in the children’s routine. At some point during this time, Andrea had a small gold bead placed on the back of her ear according to the Attention Deficit protocol developed by the National Acupuncture Detoxification Association (NADA). The second portrait shows the difference. Nothing else in the girl’s environment had changed. Clearly, Andrea was in a better space when she drew the second portrait. Michael O. Smith MD, LAc, developer of the protocol, visited the institution and observed Andrea before and again several months after the ear bead treatments began. He observed, not only a change in mannerism, but also Andrea could walk down the stairs much more easily, one foot per step. Andrea, after beads May, 2000 National Acupuncture Detoxification Association Training Manual © NADA 2008 Section VII: Client Management Issues & Strategies 99 These drawings speak for themselves. Not every patient will be as severe as Andrea, but the value of the simple placement of a bead behind the ear is obvious. Reed Academy in Massachusetts found remarkable benefit in a six week study of using the gold bead protocol for its students, boys with ADD/ADHD and other severe developmental and behavioral disorders. Parent, students, nurses and teachers ratings all showed marked improvement that lasted long after the bead intervention ended. See Appendix “F2” and “F3”. Acudetox and the Criminal Justice System Addictions and crime go hand in hand. Historically the addicted population has been a challenge to the criminal justice system, adding to cost, overcrowding, drug use within the jails/prisons, and recidivism related to relapse. Likewise the criminal justice mandated clients have traditionally challenged addictions and behavioral health treatment provision because they enter treatment begrudgingly, in total denial or with a basic conflict with the referring agency. Acudetox has become a frequently added element in successful partnerships between the criminal justice system and addictions and behavioral health treatment providers. The non-verbal aspect of acudetox allows intake staff to get beyond the court-referred client's protests and "resistance" and offer acudetox for "stress relief/, instead of forcing the issue. Acudetox creates space until the clients feel more comfortable and less threatened so they can admit their addictions and ask for help. Many providers report that acudetox actually helps the individual to let go of denial and "get honest". Acudetox and frequent urine testing combine well with criminal justice supervision to provide the paradoxical "tough love" appropriate for treating the disease of addiction. Acudetox delivered in a consistent and caring manner provides the basis for the "love" side of the equation that creates a foundation for the development of more effective discipline. Frequent urine testing provides an objective non-personalized measure of success that can be accepted equally by all parties. The counseling process can be totally separated from the process of judgment and evaluation. Discipline is separated from the difficulties of interpersonal relationships. Within this context, discipline or leniency by the judicial authority leads to constructive not escapist behavior. Positive toxicology results are primarily used to require a more prolonged or intense commitment to treatment. Drug Courts: “Drug Courts represent the coordinated efforts of the judiciary, prosecution, defense bar, probation, law enforcement, mental health, social services, and treatment communities to actively and forcefully intervene and break the cycle of substance abuse, addiction and crime. As an alternative to less effective interventions, drug courts quickly identify substance abusing offenders and place them under strict court monitoring and community supervision, coupled with effective, long-term treatment services. In this blending of systems, the drug court participant undergoes an intense regimen of substance abuse and mental health treatment, case management, drug testing, and probation supervision while reporting to regularly scheduled status hearings before a judge with specialized expertise in the drug court model. In addition, drug courts may provide job skill training, family/group counseling, and many other life-skill enhancement services. National Acupuncture Detoxification Association Training Manual © NADA 2008 Section VII: Client Management Issues & Strategies 100 In a February 2005 report, the Government Accountability Office (GAO) concluded that adult drug court programs substantially reduce crime by lowering re-arrest and conviction rates among drug court graduates well after program completion, providing overall greater cost/benefits for drug court participants and graduates than comparison group members (GAO-05-219).” National Drug Court Institute (ndci.org) The well-known "Drug Court" program in Miami-Dade County has used the acupuncture-based model since 1989. This program diverts 2,000 felony drug possession arrestees into treatment each year. More than 50 % of these clients eventually graduate the program on the basis of providing 90 consecutive negative toxicologies over the period of a year or more. A video introduction and full description of all aspects of the drug court program can be viewed at www.miamidrugcourt.com. Drug Court developed from the need to find a solution to over-crowded court dockets and a revolving door phenomenon that was clogging the court system with drug offenders in Miami, FL. In the late 1980’s Chief Judge Gerald Weatherington took his good friend and colleague, Judge Herbert Klein off of the bench and sent him out to find a solution. Judge Klein traveled the country, and finally found a model that he felt would work on a large scale when he visited Lincoln Recovery in the South Bronx of New York City. The program elements that Judge Klein found to be significant were the following: the use of acudetox as a foundation for drug treatment services, frequent urinalysis testing, an open communication style between the counselor, the client and any referring state agencies that might be involved, and an understanding between referral agencies and the treatment program that relapse was a part of recovery rather than an offense to be dealt with by pulling clients out of treatment and putting them in jail. Officials from the Miami-Dade County court system and the Dade County Office of Rehabilitative Services worked with the Lincoln staff and with NADA Trainer, Janet Konefal PhD, LAc of the University of Miami to design the court monitored diversion and treatment program that became the first Drug Court in the world. Drug courts that have acudetox components have positive reports. A follow-up study in Santa Barbara, CA, for example, showed that women who received acudetox were 50% less likely to be rearrested after being released from the county jail. The Broward County, FL Drug Court program reported a graduation rate of 90% for the group of clients receiving acupuncture, while the non-acupuncture group had a graduation rate of 56.5 %. An independent program evaluation for the drug court treatment program in Portland, OR found 76% fewer total subsequent arrests (80% fewer serious felony arrests) for program graduates than the comparison group. The researchers estimate a state cost savings of over $10 million for a two-year period. The Drug Court phenomenon has created new methods and innovations within the criminal justice and court systems. The basic model has been translated into Community Courts, Domestic Violence Courts, Mental Health Courts, Juvenile Drug National Acupuncture Detoxification Association Training Manual © NADA 2008 Section VII: Client Management Issues & Strategies 101 Court, Family and Dependency Courts, Sex-Offender Court and other models of “problem-solving justice”. Drug Court diversion and treatment programs have been established in nearly 2000 settings nationwide despite minimal access to outside funding. This expansion represents an increased commitment to addictions and behavioral health treatment throughout the U.S. Many of the Drug Court programs use acudetox as a primary component of their protocol. Acudetox is also being used in jails and prisons in the U.S. and abroad. Jail-based treatment: In addition to drug court type diversion programs, many correctional institutions have incorporated acudetox with promising outcomes. While the drug court system was in development, Dade County officials also had Dr. Konefal implement acudetox to complement the counseling services provided in the Dade County Stockade (a minimum security jail) and the neighboring TGK jail. Acudetox treatment is offered in jails and prisons through a number of different models in the U.S. and Europe, examples include pre and post release programs; programs for violent offenders and women in prison, etc. (The numbers of prisons in Europe using the NADA protocol is higher.) Sex offenders in a maximum-security prison in Oak Park Heights, MN received acudetox on a regular basis. There was a significant reduction in anger and violent intrusive sexual fantasies as compared to a control population (Culliton 1996). Early anecdotal reports for a San Francisco jail-based program for violent offenders of all sorts reveal dramatic changes in the environment. Fights on the unit, which used to occur several times per week, desisted all together. Trauma/Crisis Relief Modern acupuncturists have a history of responding to natural and man-made trauma and disaster situations around the globe. It comes as no surprise to NADA practitioners that acudetox is helpful in these situations. Working in the fields of addictions and behavioral health, clinicians see clients in crisis frequently. Crises may be related to current situations, or personal history. Whatever the source, ADSes see time and again that acudetox helps individuals and groups cope with crises. The nonverbal nature of acudetox makes it an especially appropriate tool for such situations. In the 1980’s, Mindy Fullilove, MD documented treatment for women trauma survivors at Lincoln Recovery. In 1988 an acupuncture team, lead by Maria Delores Diaz, OMD, went to Honduras and Belize following Hurricane Mitch. They trained medical personnel in basic acupuncture and acudetox techniques, and return periodically to continue training and to support ongoing availability of acupuncture in the region. National Acupuncture Detoxification Association Training Manual © NADA 2008 Section VII: Client Management Issues & Strategies 102 In 2001, NADA India practitioners provided relief to survivors and to social workers and other relief personnel following the earthquakes in Gujarat, India. Suneel Vatsayayan, of NADA India, and a colleague placing ear needles Following the terrorist attacks in New York City, many city hospitals in the area made their existing acudetox addiction treatment centers available to trauma survivors. St. Vincent’s Hospital (located closest to Ground Zero) set up a NADA-based acudetox stress clinic that offered more than 40,000 treatments to local citizens – well beyond expectations for the typical crisis outreach program. (St. Vincent’s served affected people who lived and worked in the neighborhood, their families and the providers who served them, offering acudetox, reiki and other interventions until the end of 2007.) Other acudetox teams worked around the clock immediately following the disaster, providing services to the police officers and fire fighters charged with working “the pile”. CRREW (Community Rebuilding and Relief through Education and Wellness) is an acupuncture/massage therapy team that was created out of the 9/11 disaster, and later went on to work with the NYC Fire Department and the BEAR Search and Rescue teams. In 2005, following Hurricane Katrina, NADA practitioners went to Louisiana to provide relief to the first responders. CRREW, Acupuncturists Without Borders and other acupuncture relief teams served the greater Louisiana and New Orleans population, first with teams sent in to provide on the spot treatment, and later by training local acupuncturists in the NADA protocol so that ongoing services could be provided. National Acupuncture Detoxification Association Training Manual © NADA 2008 Section VII: Client Management Issues & Strategies 103 Later, in 2005, a NADA practitioner went with Operation Heartbeat to provide relief at the site of the Himalayan earthquakes in Pakistan. While there he trained members of the Pakistani army in the NADA protocol. Marc O’Regan, of Operation Heartbeat, treats survivors and trains Pakistani Army officers in the NADA protocol following the earthquakes of 2005 In 2006 the New York City Regional Emergency Medical Response Council invited members of the crisis relief-experienced CRREW team to join their Critical Incidence Response Team. In March of the same year the U.S. government began research on the use of full-body acupuncture to treat PTSD. Walter Reed Army Medical Center offers acudetox to families, soldiers and first responders. “Acupuncture, which has few known side effects, holds promise as an effective treatment option for PTSD. Acupuncture has been shown to improve well-being and has been successfully used to treat stress, anxiety and pain conditions.” (ClinicalTrials.gov) National Acupuncture Detoxification Association Training Manual © NADA 2008 Section VII: Client Management Issues & Strategies 104 National Acupuncture Detoxification Association Training Manual © NADA 2008 Section VIII: Ethical and Legal Issues 105 Ethical and Legal Issues ADS Ethics Pledge Confidentiality/HIPPA Consent to Treatment Compliance with all federal, state and local regulations Supervision Please refer to the Acudetox Risk Management (Appendix “C”) for more details. National Acupuncture Detoxification Association Training Manual © NADA 2008 Section VIII: Ethical and Legal Issues 106 National Acupuncture Detoxification Association Training Manual © NADA 2008 Section VIII: Ethical and Legal Issues 107 Ethics Pledge for NADA Acupuncture Detoxification Specialists (ADSes) As an Acupuncture Detoxification Specialist, I pledge to 1. Believe in the dignity and worth of all human beings and to provide service for the welfare and betterment of all those served by the acudetox treatment, as endorsed by the National Acupuncture Detoxification Association (NADA); 2. Use acudetox in a supportive and nurturing way in the recognition of the right to humane treatment of suffering directly or indirectly from alcohol and drug addiction and behavioral health issues in general; 3. Never withhold treatment as punishment or use acudetox in a programmatically punitive manner; 4. Maintain a professional relationship with all persons served and to refer them to the appropriate service or practitioner promptly when this is not possible; 5. Be committed to a drug-free, sober state for all patients whose primary reason for receiving acudetox is to support their recovery from addictions; 6. Never to do anything that would weaken the physical or mental resistance of a human being, except for strictly therapeutic or prophylactic indications imposed in the interest of the patient; 7. Refrain from undertaking any activity where my personal conduct, including the abuse of alcohol or drugs, is likely to result in inferior professional services, denigrate the profession in general, or constitute a violation of law; 8. Adhere strictly to the established rules of confidentiality of all records, materials and knowledge concerning persons served in accordance with all current government regulations including but not limited to HIPAA; 9. Not associate myself with commerce in such a way as to let it influence, or appear to influence, my attitude towards the treatment of my patients; 10. Not exploit acudetox for personal gain; 11. Make an effort to keep fees within the reach of the general public and to offer sliding fee scales for those patients who require such consideration; 12. At all times to maintain the highest standards in all the services I provide, valuing competency and integrity over expediency or temporary success: 13. Support the concept that ADS training will be offered only by NADA Registered Trainers; 14. Provide accurate information regarding my education, training, experience, professional affiliations, certifications and licensure; 15. Not claim directly or by implication professional qualifications exceeding those that I have actually attained; 16. Recognize the limits of my ability, providing services only in those areas where my training and experience meet recognized professional standards; 17. Accept the fact that training in the acudetox technique does not imply competency to use acupuncture in general unless so trained and licensed; 18. Limit my practice of acupuncture to the NADA protocol unless I am a permitted to perform acupuncture in general under the scope of practice of my professional licensure; National Acupuncture Detoxification Association Training Manual © NADA 2008 Section VIII: Ethical and Legal Issues 108 19. Regularly evaluate my own professional strengths and limitations, biases and levels of effectiveness and to strive for self-improvement by seeking professional development through further education and training. When appropriate, I agree to have my technical competencies reviewed by a NADA designated consultant and/or Registered Trainer; 20. Practice acudetox in accordance with State, Provincial and/or Local regulations where such exist; 21. Seek supervision as needed and as required by State, Provincial and/or Local regulations; 22. Respect the integrity of other forms of health care and to make efforts to build bridges and develop collaborative relationships to achieve the best possible care for individual patients; 23. Use acudetox in conjunction with appropriate counseling and supportive services; 24. To contribute my ideas and finding to the general body of knowledge concerning acudetox and acupuncture for behavioral health issues; 25. Make public statements regarding the effectiveness of acudetox that are within the generally accepted experience of the profession as a whole or within the individual practitioner’s experience; 26. Use great caution in publishing discoveries and methods of treatment whose value is not yet recognized by the profession at large; and 27. Always recognize that I have assumed a serious social and professional responsibility due to the intimate nature of my work that significantly touches upon the lives of other human beings. National Acupuncture Detoxification Association Training Manual © NADA 2008 Section VIII: Ethical and Legal Issues 109 National Acupuncture Detoxification Association Training Manual © NADA 2008 Section VIII: Ethical and Legal Issues 110 Client confidentiality The implementation of the Health Insurance Portability and Accountability Act of 1996 (HIPPA) is provided for in The Standards for Privacy of Individually Identifiable Health Information (Privacy Rule). The types of programs (“covered entities”) addressed in the Privacy Rule are, “any health care provider who transmits health information in electronic form in connection with transactions for which the Secretary of HHS has adopted standards under HIPAA” (Office for Civil Rights, 2003). The type of “individually identifiable health information” protected under the Rule (“protected health information”) includes any information that identifies or can be used to identify the individual and relates to the person’s past, present or future mental or physical condition or health and to the provision of or payment for treatment to the individual. Even for programs that do not transmit data electronically, HIPPA and the Privacy Rule have become the de facto standards for assuring confidentiality of patient records. (See Appendix "G 3") There are additional Federal Laws and Regulations that address the confidentiality of addictions treatment records including 42 USC 290dd-3, 42 CFR Part 2 and 42 USC 290ee-4. These statutes prevent programs from confirming a person is a client of a program or any other identifying information, unless the client gives written permission, the program is ordered by a court, or in the case of a medical emergency. Informed Consent Because acudetox is considered an invasive procedure (i.e. the needles break the skin barrier), clients must sign an explicit, written informed consent prior to receiving acudetox treatment. This informed consent must be made part of the clients’ record and may be rescinded at any time. Failure to obtain informed consent prior to providing acudetox treatment can be legally prosecuted as a form of battery (Wagner RA, 2006). Client must voluntarily give consent without duress or coercion. For a client to provide explicit informed consent he or she must exhibit the competency to do so. Legally this means the client must be able to understand all of the options, the consequences of accepting each option and the personal cost and benefit of accepting or declining each option. The acudetox program must describe the treatment including the expected benefits and risks and the client must be able to comprehend the information. In many acudetox programs, treatment is delivered not only by acupuncturists and ADSes, but also by individuals in training. In these situations, the Informed Consent needs to clearly state that the treatment may be provided by trainees/students, in addition to licensed acupuncturists or ADSes. Compliance with State Laws, Rules and Regulations States vary dramatically regarding their laws and allowable practices for acudetox. Ethical acudetox practice then requires adherence to those laws whether or not they are more restrictive than other states. Always check State Law prior to initiating an acudetox program, including the possible need for medical history, physical examination and/or physician referral prior to needling. National Acupuncture Detoxification Association Training Manual © NADA 2008 Section VIII: Ethical and Legal Issues 111 Supervision Most states that allow non-acupuncturist ADSes require supervision of the acudetox treatment by either licensed acupuncturists or other healthcare providers whose scope of practice allows them to practice acupuncture without supervision such as physicians. In several states the statutes place the burden of assuring that paperwork is maintained according to established standards on the supervisor. Even in states where this requirement is not specifically stated, the supervisor may very well be considered the “expert” and it is his or her responsibility to assure that proper risk management measures are in place. Even if not required by state statute, have written agreements in place between the program and the supervisor and between the supervisor and ADSes and ADS trainees outlining the responsibilities and duties for which each party is responsible. In states where supervision is not required or where the ADSes are required to be acupuncturists or other healthcare providers whose scope of practice allows them to practice acupuncture without supervision, the impetus to assure safe and ethical use of acudetox falls on the ADS/healthcare provider themselves as well as the programs in which the procedure is being performed. National Acupuncture Detoxification Association Training Manual © NADA 2008 Section VIII: Ethical and Legal Issues 112 National Acupuncture Detoxification Association © NADA 2008 Training Manual Section IX: Addiction & Recovery 113 The Nature of Addiction and Recovery Models for understanding addictions and behavioral health and recovery. Treatment models (see Applications and Outcomes - Section V) Pharmacology of psychoactive substances Attendance at mutual support fellowships (see Section V) (NADA generally recommends attending at least two such meetings as part of the ADS training.) See Appendix “H 5” and www.nida.gov for more information. National Acupuncture Detoxification Association © NADA 2008 Training Manual Section IX: Addiction & Recovery 114 National Acupuncture Detoxification Association © NADA 2008 Training Manual Section IX: Addiction & Recovery 115 Models of Addiction and Behavioral Health and the Treatment Thereof There are many ways of understanding addiction. They vary with culture and current research trends. Addiction was considered through some stages of history to be a form of demonic possession or a lack of character. Since the middle of last century, medical and psychological theories and practices have adhered to more medically oriented models, such as what is often coined, “the disease model”, which considers addiction a chronic, progressive, relapsing, treatable disease often compared to others such as diabetes. The advantage of this model lies chiefly in reducing the stigma and focusing on treatment and recovery or “remission”. Current trends in medicine and research afford a vast understanding of the mechanisms of the brain involved in addiction. All models are helpful and limited. NADA does not take a position on what is the “right” model for understanding addiction. Addiction treatment also follows cultural, historical and funding-driven trends. In the United States, federal and state funded as well as privately funded treatment programs are often overseen by state agencies. NADA does not take a position on what it the “right” model of treatment, other than to encourage client-centered treatment, consistent with NADA’s model of barrier-free access to a supportive environment which repects the dignity of the individual and the importance of the personal internal foundation necessary to sustaining recovery. Addiction treatment also follows cultural, historical and funding-driven trends. In the United States, federal and state funded as well as privately funded treatment programs are often overseen by state agencies. NADA does not take a position on what it the “right” model of treatment, other than to encourage client-centered treatment, consistent with NADA’s model of barrier-free access to a supportive environment which respects the dignity of the individual and the importance of the personal internal foundation necessary to sustaining recovery. Using the vocabulary of Oriental Medicine, on which the protocol is based, the NADA treatment model accomplishes this by providing an atmosphere that is yin in its nature, which calms the empty fire exemplified by the addictive process. NADA does encourage involvement with mutual support fellowships and encourages ADSes to be familiar with 12 step and other such groups in their communities as these provide the ongoing support to recovery-living beyond treatment programs (See Section V, and Appendix “H 3”). NADA does not presume to provide a comprehensive training in addictions and behavioral health or their treatment. The National Institute of Drug Abuse, nida.gov is a good resource for those seeking further information on addiction and substances of abuse. Almost every community has good training programs available. See “H 5” for more information. National Acupuncture Detoxification Association © NADA 2008 Addiction and Recovery. Training Manual Section IX: Addiction & Recovery 116 Michael O. Smith, MD, DAc A. The nature of drug abuse 1. It all starts with the adolescent inside of us a. Need for privacy, identity, and self-esteem b. There are mood swings, over-reactions, and a loss of focus c. Some have never had a stable comfortable identity d. Others have been robbed of their self-esteem by trauma, job loss, personal crisis, etc. e. Isolation, shame and “encapsulation” ensue f. The person is fearful and wants to avoid their own consciousness g. The person abandons any faith that interpersonal communication can help resolve problems h. The person becomes self-centered and unresponsive because of failure and desperation, not out of hedonistic choice i. The person often talks about seeking pleasure and avoiding pain because this simplistic frame of references avoids any risk of painful disappointment j. The person often chooses negative and degrading relationships which match and reinforce shame when failure occurs 2. All these developments usually occur before regular drug use has begun a. Drugs offer peace at any price b. They provide a reliable escape from personal consciousness and the risk of unpredictable pain c. Addiction is the disease of “more” 3. When abusive chemicals take control of a person’s life, these changes become overwhelming and seemingly irreversible. a. Mere availability of drugs during adolescence and during adult personal crisis is dangerous b. Co-dependency involves the family and adjacent society in the addiction B. The nature of drug abuse treatment and the recovery process. 1. Adolescence is a natural process. It is the transitional passage form the dependency of childhood to the autonomy of adulthood. Even though noise and sexuality are displayed on the surface, adolescence is primarily a spiritual quest for inner selfdevelopment. It is driven by a biological clock and hence it is intrusive and painful. Nevertheless most of our adult personality was first developed and tested during adolescence. 2. Drug treatment and recovery is essentially an effort to resolve an adolescent crisis. a. Initially treatment involves the management of chemical symptoms of withdrawal and craving. b. It involves safety, social support and education about addiction and basic issues of interpersonal growth National Acupuncture Detoxification Association © NADA 2008 Training Manual Section IX: Addiction & Recovery 117 c. But, most of all, recovery means “self-help”, a rather lonely path through and adolescent terrain. d. Support groups and counselors can be helpful. They teach a person to “let go” of issues that can’t be changes and to focus efforts “one day at a time.” e. Even so, re-defining and re-discovering our self can only be done by ourselves. f. It is what we call an “inside job”. g. For many or us, adolescence is a fearful, alienating word. h. Look around you, everywhere you see people who have met the challenge of adolescence—both as teenagers and later because of trauma, personal crisis or addiction. i. As they say, “treatment works”, recovery is a realistic goal. 3. The saying “tough love” is the best description of treatment strategy. a. It represents a seemingly impossible combination of strong discipline and unquestioning support. b. Yet “tough love” is a part of any parenting or teaching effort. There is a neverending challenge to discipline and to love appropriately. c. Tough love applies to the old addicted self, but also it applies to the newly developing self. We must apply tough love to ourselves and our loved ones. d. Terms like “family values” and “just say no” trivialize this experience 3. Persons facing an adolescent crisis are delicate but they also seek out discipline. a. Those who are easily hurt often are found with sadistic companions. b. Addicted persons do not respect “enablers”. They may beg and manipulate; there is no possibility of appreciation or respect. c. It is almost impossible to give an addict anything, because everything will be bartered for more self-destruction. d. Both discipline and self-appreciation have to be re-discovered and relearned. 4. Unique difficulties which separate drug abuse treatment from other forms of health care. a. Denial and resistance. On the day we write everything down, the patient is least likely to tell the truth. b. We can’t prepare a person for a relapse and retain them in treatment. c. “My counselor said” is one of the most dangerous sentences. d. There is an immediate loss of comfort and love objects when a person enters treatment. e. It is very difficult to be soothing and supportive without enabling the addiction. f. A person must admit weakness to be helped. g. Our patients remain on the wrong side of the Serenity Prayer, that is they accepted their own failure as unchanged. National Acupuncture Detoxification Association © NADA 2008 Pharmacology of Psychoactive Substances Training Manual Section IX: Addiction & Recovery 118 Rachel Diaz, LAc VARIABLES DETERMINING DRUG EFFECT DOSE Illegal drugs have widely variable and unpredictable drug concentrations. TOLERANT DOSE LEVEL is an important factor in addicted individuals. LIPID (FAT) SOLUBILITY determines duration of drug effect. ROUTE OF INGESTION Inhalation Intravenous Swallowing Intramuscular Mucosal SET AND SETTING Set = Internal conditions of user at time of use (mood, expectation) Setting = External conditions of user at time of use (environmental factors) Other Drugs in Combination Potentiation Antagonism Adverse side effect modulation Biochemical Individuality Acute sensitivity Addiction Potential ALCOHOL ACUTE USE SYMPTOMS Sedation – drowsiness to comatose Relief of anxiety Disinhibition Impairment of motor coordination Blackout (very rapid consumption) CHRONIC USE SYMPTOMS Tolerance Liver and Brain damage Neurological damage Impotence in Males Malnutrition Memory problems Mood swings Pancreatitis Ulcers and other gastric problems Fetal abnormalities/Birth defects – FAS WITHDRAWAL EFFECTS Anxiety Tremors Heart rhythm irregularities Hallucinations – visual, auditory, tactile Convulsions Coma Death National Acupuncture Detoxification Association © NADA 2008 Training Manual Section IX: Addiction & Recovery 119 COCAINE/CRACK AMPHETAMINE/METHAMPHETAMINE (CRYSTAL, ICE) ACUTE USE SYMPTOMS PHYSICAL: Increased heart rate and blood pressure Dilated pupils Seizures Delayed ejaculation/prolonged orgasm Local anesthesia (cocaine) CHRONIC USE SYMPTOMS Tolerance Jitteriness/anxiety Weight loss Other drug use Skin picking/ulcerations Problems with memory and concentration Extreme drug craving Financial problems Fetal damage and death Binging Mood swings Insomnia Paranoia HEROIN AND OTHER OPIATES ACUTE USE SYMPTOMS Decreased heart rate, blood pressure & respiration rate Constricted pupils Drooping eyelids and slurred speech Sleepiness/sedation Nausea Relief of physical/emotional pain (analgesia) CHRONIC USE SYMPTOMS Constipation Decreased sexual interest Tolerance EMOTIONAL/BEHAVIORAL: Euphoria and hyper stimulation Decreased appetite Increased wakefulness Enhanced feelings of power/control WITHDRAWAL SYMPTOMS ACUTE Agitated depression Extreme drug craving PROLONGED Aphoria Episodic drug craving HEROIN Criminal lifestyle to support habit Lifestyle changes Hepatitis and HIV infection through needle sharing and other HIV high risk acts WITHDRAWAL EFFECTS Flu-like symptoms Runny nose, watery eyes, dilated pupils, “goose flesh”, stomach cramps/diarrhea, increased heart rate/blood pressure, intense discomfort, fear of pain (specific to opiate addicts) National Acupuncture Detoxification Association © NADA 2008 NICOTINE WITHDRAWAL SYMPTOMS Training Manual Section IX: Addiction & Recovery 120 INITIAL ACUTE PHASE 2 – 7 DAYS AFTER CESSATION Flu-like symptoms Headache Digestive and bowel disturbances Sleep disturbances Anxiety Craving Mild cognitive impairments – memory, concentration and attention problems, easy distractibility Depression PROLONGED PHASE 1 – 8 WEEKS AFTER CESSATION Episodic cravings – generally in response to conditioned cues Episodic irritability and short temper Weight gain in response to overeating MARIJUANA ACUTE USE SYMPTOMS “Red eyes” Slight impairment of short term memory Impairment of psychomotor skills Problems with concentration/attentiveness Disinhibition Panic attacks CHRONIC USE SYMPTOMS PHYSICAL Bronchitis Decreased vital lung capacity Tolerance PSYCHOLOGICAL Impaired learning Impaired motivation Impaired concentration and mental acuity WITHDRAWAL EFFECTS Irritability Drug craving Changes in appetite Sleep problems Vivid dreams National Acupuncture Detoxification Association © NADA 2008 Training Manual Section IX: Addiction & Recovery 121 FORMS OF WITHDRAWAL OR SYMPTOMS REQUIRING REFERRAL 1. ALCOHOL WITHDRAWAL Moderate to serious alcohol withdrawal with poor relief from acupuncture. • History of seizures, hallucinations, severe tremors, or hypertension with withdrawal • Long history of drinking with a recent long and/or heavy binge and an abrupt discontinuation. • Blood pressure greater than 140/90; pulse rate greater than 100 bpm. • Moderate to extreme tremor, flushing. • Anxiety, sleeplessness, withdrawal lasting more than 24—36 hours. • Convulsions, coma 2. HEROIN WITHDRAWAL • Diarrhea and vomiting over 24 hours and/or not controlled with acupuncture. • Increased symptoms with muscle cramping, gooseflesh, “crawling skin”, more than 24 hours and not managed with acupuncture. • Client’s experience continuous cravings and still live where the drug is easily available. 3. COCAINE, CRACK, METHAMPHETAMINE WITHDRAWAL • Profound depression (antidepressants may take 2 – 3 weeks to work). • Detox is relatively easy – relapse prevention is the major issue; triggers and conditioned response • Behavioral interventions are needed • Clients experience continuous craving and still live where the drug is available National Acupuncture Detoxification Association © NADA 2008 Substance Abuse Disorders Training Manual Section IX: Addiction & Recovery 122 Diagnostic and Statistical Manual 4th Edition (DSM-IV) of the American Psychiatric Association Criteria for Substance Dependence 1. A maladaptive pattern of substance use, leading to clinically significant impairment or distress, as manifested by three (or more) of the following, occurring at any time in the same 12-month period: 2. tolerance, as defined by either of the following: o a need for markedly increased amounts of substance to achieve intoxication or desired effect o markedly diminished effect with continued use of the same amount of substance 3. withdrawal, as manifested by either of the following: o the characteristic withdrawal syndrome for the substance o the same (or a closely related substance is taken to relieve or avoid withdrawal symptoms 4. the substance is often taken in larger amounts or over a longer period that was intended 5. there is a persistent desire to unsuccessful efforts to cut down or control substance use 6. a great deal of time is spent in activities necessary to obtain the substance (e.g. visiting multiple doctors or driving long distances), use the substance (e.g. chain smoking), or recover from its effects 7. important social, occupational, or recreational activities are given up or reduced because of substance use 8. the substance use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance (e.g. current cocaine use despite recognition of cocaine-induced depression, or continued drinking despite recognition that an ulcer was made worse by alcohol consumption) Specify if: With Physiological Dependence: evidence of tolerance or withdrawal (i.e. either Item 1 or 2 is present) With Psychological Dependence: no evidence of tolerance or withdrawal (i.e. neither Item 1 or 2 is present) National Acupuncture Detoxification Association © NADA 2008 Criteria for Substance Abuse • Training Manual Section IX: Addiction & Recovery 123 • A maladaptive pattern of substance use leading to clinically significant impairment or distress, as manifested by one (or more) of the following occurring within a 12 month period: 1. recurrent substance use resulting in a failure to fulfill major role obligations at work, school, or home (e.g. repeated absences or poor work performance related to substance use; substance-related absences, suspensions or expulsions from school; neglect of children or household) 2. recurrent substance use in situations in which it is physically hazardous (e.g. driving an automobile or operating a machine when impaired by substance use) 3. recurrent substance-related legal problems (e.g. arrests for substance related disorderly conduct) 4. continued substance use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the substance (e.g. arguments with spouse about consequences of intoxication, physical fights) The symptoms have never met the criteria for substance dependency for this class of substance Criteria for Substance Intoxication • • The development of a reversible substance-specific syndrome due to recent ingestion of (or exposure to) a substance. Note: Different substances may produce similar or identical syndromes. Clinically significant maladaptive behavioral or psychological changes that are due to the effect of the substance on the central nervous system (e.g. belligerence, mood lability, cognitive impairment, impaired judgment, impaired social or occupational functioning) and develop during or shortly after use of the substance. The symptoms are not due to a general medical condition and are not better accounted for by another mental disorder • Criteria for Substance Withdrawal • • • The development of substance specific syndrome due to the cessation of (or reduction in) substance use that has been heavy or prolonged. The substance-specific syndrome caused clinically significant distress or impairment in social, occupational, or other important areas of functioning. The symptoms are not due to a general medical condition and are not better accounted for by another mental disorder. National Acupuncture Detoxification Association © NADA 2008 Training Manual Section IX: Addiction & Recovery 124 National Acupuncture Detoxification Association © NADA 2008 Training Manual Section X: Appendices 125 Appendices A. The Lincoln Story B. Sample Client Information and Forms C. Acudetox Risk Management D. Research E. Excerpts from Treatment Improvement Protocol (TIP) 45 F. Special Populations G. Sample Program Forms H. Selected Manuscripts on Addiction and Recovery I. Supplies, Vendors, Publications J. Acudetox References 127 131 136 147 159 162 177 181 199 205 National Acupuncture Detoxification Association © NADA 2008 Training Manual Section X: Appendices 126 National Acupuncture Detoxification Association © NADA 2008 Appendix “A” The Lincoln Story Training Manual Section X: Appendices 127 with excerpts from “Fighting Drug Abuse with Acupuncture by Ellinor R. Mitchell NADA, the organization, and the NADA 5-point protocol directly attribute one place and time as their origin. The birthplace of acudetox was originally known as the Acupuncture Clinic, Substance Abuse Division of the Department of Psychiatry of Lincoln Hospital; later known as Lincoln Detox; and currently known as Lincoln Recovery. Lincoln Recovery was established in 1970 in response to community needs, and was created via community activism. Initially, methadone was used to detox clients from heroin. By 1974 acupuncture had been introduced and became an integral service in the clinic. The program was created in the community-based self-help model, as a result of a community activist response to the growing drug problem and lack of services available. A small contingent of professional medical staff was supplemented by many neighborhood volunteers in a collective and non-hierarchical model. The circumstances which necessitated the program also shaped its design and growth. Those same grassroots strategies pervaded the spread of the acudetox culture with the development of the organization, NADA, and the proliferation of NADA-styled treatment programs across the country and around the world. To understand the birth of Lincoln Recovery and the development of acupuncture in its use, it is important to review the times in which it came into being. In 1970 New York City, an addicted person could wait a year to receive a slot in a treatment program. Those familiar with addiction understand that many negative things can happen to an individual, their family members and to the societal context where they live, use and support their habits. It was not uncommon for an addicted person to die from drug-related causes before their opportunity for treatment arose. Also in 1970, a common strategy for dealing with the lack of responsiveness of municipal government was the practice of civil demonstrations. The often powerless in our society took to sit-ins and other disruptive demonstrations to force action from the leaders. In November of that year a confluence of activist groups created the United Bronx Drug Fighters, and demanded the creation of a drugdetoxification center at the local Bronx public hospital. At the time, Lincoln Hospital had no drug treatment program. Community activists had a large hand in making the program happen, and therefore felt they had a stake in administering the program. Within the cultural context there was a demand for neighborhoods to develop their own programs and treat their own ills. The Young Lords, a radical Puerto Rican group and the Black Panthers, a militant black group were both part of the community forces that came together to provide social services to their communities. These programs included not only addictions treatment, but also generalized health clinics, breakfast programs for disadvantaged children and other social services. The influence of these counter-culture groups was definitely felt within the structure and function of Lincoln Recovery. The groups provided political education classes and instructions on how to navigate the often red-tape ridden social services provided by local government, as well as security for the addiction treatment clinic. National Acupuncture Detoxification Association © NADA 2008 Training Manual Section X: Appendices 128 Lincoln Recovery was initially an outpatient detoxification program, using methadone. It was the first of its kind. Prior to this, there were outpatient methadone maintenance programs, but none were detox programs. The idea was generated from the experience of one man, Butch Ford, who had been detoxing people with methadone in the basement of his Bronx home. Based on Butch’s experience and his success in detoxing a number of people in the neighborhood, it was decided that when the community came together to create a program that it would follow his methods. According to NADA founder and long-time director of the Lincoln Recovery Program, Michael O. Smith MD, DAc, “we had gotten a lot of doctors at Lincoln to be willing to double up in their dorm rooms so that we could really run a detox unit at Lincoln… “When the day came, at noon we just walked in and took the elevator and went up to the sixth floor… Later in the day there was a symbolic arrest of a few people in the program. That lasted a few hours. “Over that weekend there was a discussion with then chairman of psychiatry, Gabe Koz, and some of us who were involved. And they said, ‘Well, Monday morning we’re going to do an outpatient methadone detox program.’ “There were about 200 people waiting in line the next day…..we asked people waiting in line if they could help read and write, and do some of the paperwork.” The current staff design was born out of that need, from day one, of a support staff system that combined the knowledge and experience of former clients to augment the small clinical staff. “We had a huge volunteer group,” Smith said, “and we started in the auditorium of Lincoln Hospital. We were an innovative program from the beginning. We were the only outpatient detox program. And we immediately served a lot of patients in the hospital. Nursing people, a lot of people were very sympathetic, because this was a service-oriented thing.” The addition of acupuncture to program services began sometime in either late 1973 or early 1974. Many of the staff had concerns about the use of addictive drugs to treat substance abuse. When Dr. Wen, in Hong Kong, published results of success with heroin addicts using acupuncture, the staff at Lincoln became interested in the method. Not only the staff, but also the clients were interested in natural methods, and demanding nonpharmaceutical resources. A long-time staffer at the program noted, “It was the clients that wanted something else besides methadone. We had old methadone users—I’m talking 30, 35, 40 years, which is old in addiction – and they wanted another method of detox, because they didn’t like the methadone. They were really dead set on us finding another method for them to detox and stay clean. That’s how we really got into acupuncture.” The staff sought acupuncturists who would come to Lincoln and demonstrate. Many donated their time to the pioneer program. They started with the protocol used at Kwong Wah Hospital, which was to needle the Lung point on the ear and add electrical stimulation. The effect lasted for about 6 hours. Eventually the electrical-stimulator broke. The staff discovered, much to their surprise, that the nonelectro potentiated treatment had a more prolonged effect. National Acupuncture Detoxification Association © NADA 2008 Training Manual Section X: Appendices 129 This development had a major effect on the proliferation of the acupuncture treatment. Using plain needling (without stimulation) was a more flexible and less expensive process. It was easier to learn and more easily replicated as the protocol was modeled in other treatment programs. The eastern philosophy of less is more was proven to be true. Once the effectiveness of the acupuncture was established, many of the Lincoln staff, including Dr. Smith, went on to study acupuncture. Over time, and with much experimentation of various ear and body points, the current 5-point NADA protocol was developed. The early emphasis on grassroots involvement that created Lincoln Recovery has always flavored the means with which acudetox has spread. Many of the initial program founders and workers have passed, or their radical and anti-establishment methods caught up with them. Among those important program generators are Jose Aponte, Matulu Shakur, and Richard Taft MD. The story of Dr. Richard Taft’s death, probable murder, soon after the launch of Lincoln’s acupuncture program is one illustration of the tenacity of the program. Dr. Taft was found dead in the storage closet of the auditorium at Lincoln Recovery, where much of the program activity took place. There was an apparent attempt to make his death look like a drug overdose, potentially harming the program’s reputation. However, those familiar with drug effects could easily tell that this was not the case. He was found lying on his side, in an unnatural position, as though his body had been fit into a small space after death. His long sleeve shirt and jean jacket were buttoned at the cuff (which could not have happened in the event of a heroin overdose). There was drug paraphernalia near him, but no matches, no cooker or keys to the room (which was always kept locked) and both doors were ajar. His wallet and money were found on his body. The coroners report found no needle marks and no heroin in his urine. However heroin was found in his tissues. His body had a large bruise and indentations in the back of the head, as well as scratches on his wrists. He was not addicted to heroin, nor was he suicidal. A fresh needle mark should have been very easily found. Two months prior to his death, Dr. Taft had received death threats, had begun carrying a weapon for protection, and he had noted to colleagues that he was in fear for his life. On the day of his death he was scheduled to meet a high ranking Washington official regarding funding for the Lincoln Detox Acupuncture Program. The Washington officials did arrive at Lincoln later that same day. However, the moment they entered Lincoln Recovery a bomb threat was telephoned in to the hospital. The hospital newsletter carried an accounting of the entire questionable incident along with the following eulogy: “In Memory of Richard Taft “Richard Taft, a man, a doctor and above all, a revolutionary. As a man he supported the right and fought the wrong. “For over four years he served in the South Bronx community. He served for one year as medical doctor in the People’s Program, Lincoln Detox. He was instrumental in training paramedics and researching acupuncture as the non-chemical treatment from narcotic withdrawal. It is perhaps this involvement that led to his death. National Acupuncture Detoxification Association © NADA 2008 Training Manual Section X: Appendices 130 “He dedicated his life to help people fight their addiction problems with his medical and acupuncture knowledge. It was this dedication that made him continue his work even under the threat of death, even after being shot at. STOP THE DRUG PLAGUE!” Dr. Smith noted that after Richard’s death many at Lincoln thought the program would be shut down. That reality failed to materialize. This left Smith, who had been providing medical services in the basement floor of the building, to take on the role of director of the program. Characteristic of the service orientation of the program, even as Dr. Taft’s body was found and police arrived to investigate, the auditorium filled with clients and treatment continued without missing a step. However controversy continued to follow the program. In the late 1970’s it became a target, as did many social programs, of political attack. The fact that security for the treatment center was run by radical ethnic groups was used against the program. On the Monday after Thanksgiving in 1978 the hospital chained the doors to the program and did not let anyone associated with the program, including staff, enter the building. The programs records and equipment were inaccessible. The staff thought that the end had finally come. However, there was another location nearby, a former Public Health Station, which was sometimes used for program services. Staff picked up and moved down the street and around the corner to the current location for Lincoln Recovery. It was expected that they would be followed and shut down again, but that never happened. One staff member noted, “We couldn’t bring methadone over here because this building is not good on security. We had to quit giving out methadone. Then we had to really get into acupuncture full-time. We were getting away from methadone, anyway, because it was a drug, and we were against drugs.” The relocation of the program was not an easy transition. The place was a “dump”. At times they worked with umbrellas over their heads. There was no heat in the building. The staff performed housekeeping services because the hospital did not provide them. They also did outreach to the community by providing mobile units that would set up in specified areas within the neighborhood to provide additional services. Anyone visiting Lincoln Recovery today may notice the modest surroundings and an environment that continues to speak to the community’s ownership of the program. For an addict this is important. The treatment center must be the place that they are most comfortable returning to, even when they feel their worst. Clients are naturally encouraged to seek treatment in times of trouble because the treatment center fits who they are and reflects the local culture. The grassroots efforts by the founders of the People’s Program at Lincoln and their desire to create a program that was built for the community by the community has withstood the test of time and proliferated across the globe. The intention to provide accessible methods of serving an urban community developed into a model of treatment that fits current customs, but harkens back to the “barefoot doctor” tradition of acupuncture as healthcare for the masses in rural China. The cultural consequence of 20th century radicalism resulted in NADA’s emphasis on barrier-free, drug-free access to care. National Acupuncture Detoxification Association © NADA 2008 Training Manual Section X: Appendices 131 Appendix “B” Client Information “B 1” Acudetox Client Instructions This program offers acudetox to assist your recovery process. Here are a few suggestions for you to follow: Try to eat before you have a treatment. When possible try not to have coffee, cigarettes, or heavy meals for about one hour before and after treatment (but don’t skip acudetox if you do). It is a good idea to use the restroom before treatment. Remind the Acupuncture Detoxification Specialist (ADS) each day if you are a hemophiliac/”bleeder”. Have your ears accessible, but you do not need to remove earrings or hats. If you have long hair, braids or dreadlocks, it is a good idea to tie your hair back so the needles don’t get knocked out. Prepare your ears with an alcohol soaked cotton ball or wipe, take a seat and relax. If you are taking antabuse or Flagyl, use soap and water or other non-alcohol based cleanser to clean your ears. Acudetox is nearly painless, but some people experience a brief pinch when the needles go in. The ADS can show you how to breathe deeply to minimize discomfort. If you have a respiratory condition, just breathe in as relaxed a manner as possible. Once the needles are placed the sharp sensation goes away. If you experience any discomfort during the treatment, notify the ADS who can adjust the needles slightly. Some people feel sensations such as warmth, tingling, itching or electrical sensation from the needles. These are normal. It is better to sit with your feet flat on the floor and your arms uncrossed. Treatment time will be relaxing and stress releasing. You may fall asleep. We encourage silence or quiet conversation. Please respect yourself and other clients by keeping the noise level down. If one of your needles falls out and is easily visible and accessible you may retrieve it and notify the ADS. Do NOT touch any needle that is not yours! Sit quietly with the needles for forty-five minutes. Remove your needles when you are done or notify the ADS. Occasionally, a point will bleed when the needle is removed. This is normal also. Press a dry cotton ball or Qtip to the site for thirty seconds. Dispose of all needles and blood contaminated cotton balls in the red/biohazard containers. We need your help to make sure no needles are lost. Please keep count of the number of needles you put into the container and search carefully for any that may have fallen to the ground. Please do NOT put needles into the trash container. You may feel sleepy after the first few treatments. With regular acudetox you may sleep better, feel more rested, have more energy, and think more clearly. Some people don’t notice any particular change related to the acudetox except that they are not using drugs/alcohol or engaging in compulsive behaviors. Treatment may also stimulate the release of emotions for some people. It is important to acknowledge these feelings as part of the healing and recovery process. Remember, recovery from any substance or behavioral compulsion is an ongoing process. Acudetox supports the process at every stage. It helps establish balance in life. If available, enjoy a cup of Sleepmix/herbal tea following your treatment. It is not a narcotic or sedative, but will help you relax and sleep better at night. It is safe and non-addictive and a good alternative to the over stimulation of coffee or soft drinks. It helps to drink a cup at bedtime too. Acudetox treatments have a cumulative effect. Come back as often and as substance free as you can. National Acupuncture Detoxification Association © NADA 2008 Training Manual Section X: Appendices 132 National Acupuncture Detoxification Association © NADA 2008 Training Manual Section X: Appendices 133 “B 2” Client Handout Acupuncture!! What is it? How does it work? Why the ears? Effective for treating addiction! …Acupuncture is the world’s oldest medical science. It has been around for over 3,000 years. …Chinese medical science holds that there is an extensive and complex energy system that flows throughout the human body. When this stream flows freely, the body is in balance and healthy. Interruptions and blockages in this normally free-flowing energy stream causes stagnation, illness, disease and discomfort. Simply stated, acupuncture is a technique that helps get the energy flowing freely and restore balance to the body. In terms of modern medicine, acupuncture creates healing changes in the various functional systems of the body. …Acudetox auricular (ear) acupuncture is based on the fact that there are points for the entire body mapped out on the ear’s surface. …the National Acupuncture Detoxification Association (NADA) has developed a protocol to treat addiction using five points on each ear: Shenmen or Spirit Gate – used for calming and relaxing Sympathetic – used for relieving tension Liver – used to detoxify, as well as to relax and relieve anger and frustration Kidney – used to strengthen the willpower and release unwanted toxins Lung – used to help respiration, as well as for detoxification. National Acupuncture Detoxification Association © NADA 2008 Training Manual Section X: Appendices 134 National Acupuncture Detoxification Association © NADA 2008 Training Manual Section X: Appendices 135 Lianne Audette LAc National Acupuncture Detoxification Association © NADA 2008 “B 3” Client Evaluation Training Manual Section X: Appendices 136 ACUDETOX CLIENT TREATMENT EVALUATION Please read the statements below. Place a check mark in the space before any statements which apply to you. Mark as many as apply. Statement: Since participating in acudetox treatment I have experienced the following changes: ___ A reduction in chronic pain ___ A reduction in my levels of depression/anxiety ___ Feelings of guilt concerning my past behavior have lessened. ___ My cravings for alcohol/drugs have lessened. ___ I am in better control of my anger. ___ I am more at ease in my interactions with others. ___ I find it easier to participate in peer group therapy. ___ I worry less about trivial things. ___ My fears have diminished ___ a little ___ greatly. ___ I find I am more accepting of my substance abuse problems. ___ I feel better about myself. ___ My self-esteem has improved. ___ Hostility towards others has diminished. ___ My resentments have decreased. ___ My sleep pattern has improved. ___ My thinking is clearer. ___ I feel less stressed. ___ My overall energy has improved. ___ Acudetox treatment has been very helpful. ___ Acudetox treatment has been a little helpful. ___ Acudetox treatment has been of no help. Thank you for your participation in this survey. ______________________________ Name _____________________ Date National Acupuncture Detoxification Association © NADA 2008 Training Manual Section X: Appendices 137 Appendix “C”: Acudetox Risk Management Acudetox Risk Management From its original inception as an alternative to medication-assisted detoxification at Lincoln Hospital, the acudetox protocol is finding its way into a broad spectrum of clinical scenarios. As the use of acudetox grows, it is important that all parties associated with the treatment – the clients as well as those delivering, supervising, cleaning up after the treatment and the programs in which the procedure is performed – remain safe and their risk of adverse events minimized. While acudetox is generally considered a relatively safe procedure, as is acupuncture in general, there are none-the-less certain inherent risks to which clients, Acupuncture Detoxification Specialists (ADSes), acudetox supervisors, cleaning personnel and programs may be exposed. These risks include accidental needle sticks, exposure to blood borne pathogens, adverse reactions to the treatment (rare), improper staff responses to adverse clinical events, failure to obtain proper informed consent and maintain patient confidentiality, improper disposal of used needles and failure to abide by federal, state and local laws and regulations. Fortunately there are established risk management strategies that can minimize if not completely eliminate the chance of adverse events occurring in a NADA-style treatment program. In the event that an adverse event does occur, having written procedures in place and maintaining rapport and open communications will lessen the potential for negative outcomes from the occurrence. Risk management is the process of assessing situations for potential risks and developing and implementing strategies to manage and mitigate their occurrences. These strategies include avoiding the risk, reducing the negative outcomes of the risk and accepting the consequences of the risk. For acudetox Programs this means: • following Universal Precautions and Clean Needle Technique procedures, • utilizing recognized engineering controls (e.g. sharps containers) and personal protective equipment (where required or desired), • obtaining explicit informed consent and assuring confidentiality of client records, • establishing and maintaining proper rapport between the program staff and the clients, • having written supervision agreements in place (when supervision of ADSes is required), and • assuring ADSes and acudetox supervisors are able to identify and respond to adverse clinical events. Programs along with their acudetox supervisors and non-managerial ADSes must develop and implement an appropriate Exposure Control Plan as required by OSHA. Programs must also provide annual blood borne pathogens training to all personnel who have a reasonable risk of exposure to contaminated acupuncture needles and other materials that may have become contaminated by a patient’s blood or other body fluids. Programs, ADSes and acudetox supervisors must also be familiar with and abide by federal, state and local laws as they pertain to the acupuncture in general and acudetox in particular. Before discussing how to establish risk management strategies within an acudetox program, some background information will be presented. Acupuncturists, nurses, doctors and certain other healthcare professionals will likely be familiar with Universal Precautions, Blood borne Pathogens and Exposure Control, and the Needlestick Safety and Prevention Act and can use this material as a review of these concepts. For those not familiar with these topics, it is suggested that the reader consult the references for more detailed presentations of this material or seek the advice of experts in National Acupuncture Detoxification Association © NADA 2008 Training Manual Section X: Appendices 138 these areas. While not intended to be an exhaustive treatise on these subjects, the topics of needle removal, client confidentiality, Informed Consent, medical histories, and ADS supervision are also presented. The concept of a Risk Cascade is reviewed followed by strategies to reduce risks to the clients, ADSes, supervisors and programs. This information is provided as guidance and it is up to each program, ADS and supervisor to adapt these concepts to the specific clinical scenario. Background information Universal precautions and blood borne pathogens The Centers for Disease Control and Prevention (CDC) define Universal Precautions as “a set of precautions designed to prevent transmission of human immunodeficiency virus (HIV), hepatitis B virus (HBV), and other blood borne pathogens when providing first aid or health care. Under universal precautions, blood and certain body fluids of all patients are considered potentially infectious for HIV, HBV and other blood borne pathogens” (Centers for Disease Control and Prevention, 2005). In other words, all human blood and certain other human body fluids are treated as if known to be infectious for blood borne pathogens. While Universal Precautions cover many types of body fluids, in acudetox settings blood is the fluid of concern as on occasion clients’ ears may bleed after the removal of the needles (Universal Precautions do not apply to sweat, tears, nasal secretions or saliva unless they contain visible blood). Universal Precautions include the use of Personal Protective Equipment such as gloves when there is a reasonable chance of the healthcare provider coming in contract with clients’ body fluids or contaminated items (defined as “the presence or reasonably anticipated presence of blood or other potentially infectious materials on an item or surface”) as well as measures to prevent inadvertent needle sticks. The Clean Needle Technique for Acupuncturists (CNT) is the recognized standard of care for the acupuncture profession in regards to blood borne pathogens and needle stick prevention (National Acupuncture Foundation, 1997). The 5th edition includes special provisions for performing acupuncture in public health settings that outlines specific modifications of the standard techniques. While this manual is the de facto standard for the acupuncture profession, as will be noted shortly, programs are required by federal law to abide by the regulations prescribed by OSHA and other federal entities. There are several factors that influence the overall risk of exposure to blood borne pathogens including the number of infected individuals in the client population, the pathogen involved, the type of exposure (e.g. needle stick versus skin contact), the amount of blood involved and number of blood contacts (Centers for Disease Control and Prevention, 2003). Several larger metropolitan areas report at least 90% of IV drug users are positive for HBV, hepatitis C (HCV) and/or HIV. Even so, very few exposures result in infection. Because acupuncture needles are solid (as opposed to hollow-bore hypodermic needles), they carry very little risk of carrying infected blood. With proper diligence inadvertent needle sticks with contaminated needles should never occur. Proper disposal of blood-contaminated items such as used cotton balls further decrease the chances of blood borne pathogens exposure. Because of the high occurrence of HBV infection among IV drug users, the Centers for Disease Control and Prevention recommend universal HBV vaccination for National Acupuncture Detoxification Association © NADA 2008 Training Manual Section X: Appendices 139 individuals who work in facilities in which these clients are treated (Center for Disease Control and Prevention, Healthcare settings serving IDUs). Because the vaccinations are given via injection and therefore considered invasive, programs cannot mandate that their employees receive the vaccination series. ADSes are advised to consider the vaccination series if they have not already done so. ADS safety and exposure control The Occupational Safety and Health Administration (OSHA) exists to assure the safety and health of workers in the US. Because most ADSes are either employees, consultants or volunteers of a program they fall under the auspices of OSHA regulations (whereas self-employed, unincorporated, private practice acupuncturists and other unincorporated healthcare providers with no employees or other persons practicing in their offices do not). The blood borne pathogens standards are Federal regulations (29 CFR 1910.1030) established by the Needlestick Safety and Prevention Act (Congressional Record, 2000) and enforced by OSHA. These regulations apply to all employers that have workers with reasonable expectations of occupational exposure to blood or other potentially infectious materials (OPIM) (Office of the Federal Register, 2006). Included in this standard is the requirement for a written Exposure Control Plan that must include a system for reporting exposure, information on testing for infection, treatment options available and monitoring for side effects of treatment (certain smaller clinics may be exempt from keeping injury and illness records, including sharps injuries logs, but are still required to otherwise be in compliance with the blood borne pathogens standard). The full text of 29 CFR 1910.1030 including the components of an Exposure Control plan can be downloaded from the Office of the Federal Register’s website listed in the Reference Section. As part of their Exposure Control Plan, programs along with their acudetox supervisor and ADSes must evaluate the need for Personal Protective Equipment (PPE), which for NADA style programs is generally limited to the use of gloves by ADSes during needle removal. Factors to consider in whether to require gloves while removing needles include the type and number of clients served and the experience of the ADSes. Whether or not a program requires the use of gloves when removing needles, OSHA requires that PPE be available for workers if they desire to use them. While not legally considered PPE, closed-toe shoes should be worn by ADSes to prevent inadvertent needle sticks from dropped needles. Tuberculosis (TB) exposure is another concern in several metropolitan areas. The Centers for Disease Control and Prevention suggest that programs develop a TB exposure control plan designed to reduce the risk of TB transmission between clients and patients. Staff should be encouraged and can be required to undergo regular purified protein derivative (PPD) testing. Even very low risk programs should have a written procedure for how to proceed if a client with known or suspected active TB is encountered. Needle removal The practitioner or the clients can remove needles. There are risks and benefits of each model. (Programs will need to set policy/procedure that best suits their situation.) National Acupuncture Detoxification Association © NADA 2008 • Training Manual Section X: Appendices 140 • Clients remove needles: Under supervision, clients remove their own needles and staunch any bleeding that occurs (using either a cotton ball or a cottontipped swab). It may be helpful to provide a station with a mirror, a biohazard container, cotton balls/swabs and hand cleaner, and a system for counting needles. Clients must wash their hands with soap and water, alcohol-based hand rubs, antibacterial gel, wipes or foam after removing needles whether or not there was visible blood present. ADSes remove needles: ADSes remove needles one at a time and put each needle directly into the red sharps container watching it all the way into the container. Whether or not the ADSes are required to wear PPE must part of the program’s Exposure Control Plan. Cotton balls or cotton-tipped swabs must be with the ADS. Give cotton balls to client to staunch bleeding or hold a swab on the site for several seconds with firm pressure. If the ADS is wearing gloves and any blood gets on them, the gloves must be disposed as outlined in the program’s Exposure Control Plan and a fresh pair donned before going on to the next client (please note that while they prevent contact with blood, gloves do not protect against needle sticks). If the ADS gets blood on his or her hands, then the procedures outlined in the programs Exposure Control Plan must be implemented. Client confidentiality The implementation of the Health Insurance Portability and Accountability Act of 1996 (HIPPA) is provided for in The Standards for Privacy of Individually Identifiable Health Information (Privacy Rule). The types of programs (“covered entities”) addressed in the Privacy Rule are, “any health care provider who transmits health information in electronic form in connection with transactions for which the Secretary of HHS has adopted standards under HIPAA” (Office for Civil Rights, 2003). The type of “individually identifiable health information” protected under the Rule (“protected health information”) includes any information that identifies or can be used to identify the individual and relates to the person’s past, present or future mental or physical condition or health and to the provision of or payment for treatment to the individual. Even for programs that do not transmit data electronically, HIPPA and the Privacy Rule have become the de facto standards for assuring confidentiality of patient records. There are additional Federal Laws and Regulations that address the confidentiality of addictions treatment records including 42 USC 290dd-3, 42 CFR Part 2 and 42 USC 290ee-4. These statutes prevent programs from confirming a person is a client of a program unless the client gives written permission, the program is ordered by a court or in the case of a medical emergency. Informed Consent Because acudetox is considered an invasive procedure (i.e. the needles break the skin barrier), clients must sign an explicit (written) informed consent prior to receiving treatment. This informed consent must be made part of the clients’ files and may be rescinded at any time. Failure to obtain informed consent prior to providing acudetox National Acupuncture Detoxification Association © NADA 2008 Training Manual Section X: Appendices 141 treatment can be legally prosecuted as a form of battery (Wagner RA, 2006). Client must voluntarily give their consents without duress or coercion. For a patient to provide explicit informed consent he or she must exhibit the competency (have the capacity) to do so. Legally this means the client must be able to understand all of the options, the consequences of accepting each option and the personal cost and benefit of accepting or declining each option. The acudetox program must describe the treatment including the expected benefits and risks and the client must be able to comprehend the information. In many acudetox programs, treatment is delivered not only by acupuncturists and ADSes, but also by individuals accumulating the required clinical hours to receive their ADS Certificate of Completion. In these situations, the Informed Consent must clearly state that the treatment may be provided by trainees/students in addition to licensed acupuncturists or ADSes. Medical History/Physical Exam/Physician Referral Some states require that prior to receiving acupuncture treatments; clients must give a medical history, have a physical exam, and/or have a referral from a physician. Because acudetox is considered an acupuncture treatment, acudetox clients may fall under these regulations. State laws must always be checked prior to initiating an acudetox program including the need for medical history, exam and or referral. Supervision Most states that allow non-acupuncturist ADSes require supervision of the acudetox treatment by either licensed acupuncturists or other healthcare providers whose scope of practice allows them to practice acupuncture without supervision. In several states the statutes places the burden of assuring that paperwork is maintained according to established standards on the supervisor. Even in states where this requirement is not specifically stated the supervisor may very well be considered the “expert” and it is his or her responsibility to assure that proper risk management measures are in place. In states where supervision is not required or where the ADSes are acupuncturists or other healthcare providers whose scope of practice allows them to practice acupuncture without supervision the impetus to assure safe and ethical use of acudetox falls on them as well as the programs in which the procedure is being performed. Risk Cascade As already indicated, risk management involves identifying potential risks and minimizing, if not completely eliminating, their potential for occurrence. In other words, do no harm while doing some good (which coincidentally is an underlying theme within NADA-style treatment). There are certain dimensions of risk that need to be examined and planned for accordingly and these dimensions often fall into the following cascade of events (Kailin DC, 1997 pgs. 13 - 16): • Material harm: the actual physical damage to the person. • Perceived harm: the impression of the harm perceived by the individual. National Acupuncture Detoxification Association © NADA 2008 • Training Manual Section X: Appendices 142 Relational failure: the failure to establish and maintain rapport. Rapport or the lack thereof will generally affect the level of harm perceived by a person relative to the actual material harm sustained. • Consumer legal action: failure to establish and maintain rapport will often lead to the individual perceiving much greater harm than actually materially occurred and may lead to the consumer (client) seeking legal remedy against the ADS, acudetox supervisor and/or program. Conversely establishing and maintaining rapport will often have the client perceiving a lesser degree of harm. • Regulatory action: failure to establish and maintain rapport can also result in complaints to licensing bodies (e.g. state boards) by consumers that can lead to investigations and sanctions against ADSes, acudetox supervisors and/or programs. Programs can also institute sanctions against its ADSes and/or acudetox supervisors based on internal complaints or observations. • Repercussions: the negative outcomes to the ADSes, acudetox supervisors and/or programs from legal and regulatory actions. These may include monetary costs and fines, loss or restrictions of licensure, embarrassment to the individuals and the programs, termination of acudetox treatment within programs and cancellation of malpractice insurance. The primary material harm risk involved with acudetox centers around the use of acupuncture needles. Possible but rare risks to the client involve infection, inadvertently being stuck with a contaminated needle, exposure to another client’s blood and injuries secondary to an adverse reaction to the treatment (which are very, very rare). ADSes face risks from inadvertent needle sticks and coming in contact with clients’ blood. In addition, cleaning personnel can also be inadvertently stuck by a stray needle as can other staff or clients if the acudetox room is used for other purposes. Fortunately the material harm aspect of risk can be significantly reduced if not completely eliminated by following Universal Precautions, Clean Needle Technique and the guidelines set forth in this manual as part of NADA ADS training. Establishing and maintaining rapport with the clients will generally reduce the perception of any material harm and therefore mitigate the chances of legal actions and regulatory complaints. Risk minimization Minimizing risks within an acudetox program can also be viewed as a cascade. Reducing the risk of material and perceived harm to clients is the most important aspect of a Risk Management Protocol, followed by risk to the ADSes. Minimizing risks to these groups will result in safe and effective NADA-style programs thereby mitigating risks to programs themselves, program administrators and acudetox supervisors. Minimizing risk to clients • Clients should be reminded verbally and/or via posted instructions of the program rules regarding client safety. New clients should be reminded before their first group needling session even if they received these instructions in an orientation session. Program rules should include: o not to play with any needles that fall out during treatment, National Acupuncture Detoxification Association © NADA 2008 Training Manual Section X: Appendices 143 • • • • • • • • • o to secure his or her own fallen needles in whatever manner the program has established that protects others from contacting the contaminated needles. (e.g. in carpet, through pants, in a safe, visible location, etc.), o not to touch another client’s fallen needles, o that there is no walking around while the needles are in, o they are not to lie on the floor in the general area of where the needling takes place. For clients with back problems, special arrangements can be made for the client to lie down away from where he or she may contact other clients’ fallen needles, o Clients should be requested to use the restroom prior to treatment. If a client does need to use the restroom during treatment, an ADS should remove all needles and replace them with sterile, unused needles when the client returns. ADSes must wash hands thoroughly before and after the treatment session with both soap and water or with alcohol-based hand rubs. If these are not available, then the ADSes must use antibacterial gel, wipes or foam. If the ADSes hands become contaminated during needling, he or she must clean his or her hands prior to treating the next client. Clients must prepare the surface of their ears with an alcohol swab or alcoholsoaked cotton ball. Clients on disulfam/Antabuse can use a non-alcohol based preparation or use soap and water. Use only pre-sterilized, single-use needles from unopened packages. Discard any needles if the tips have touched any surface other that the intended ear point and any unused needles at the end of the treatment day. ADSes must always follow the guidelines in this manual for proper needling technique. While being needled sitting in chairs, clients must be sitting straight up with both feet on the floor (once needles are in clients can adopt a more comfortable sitting position). Used needles must go into a red sharps container. ADSes must follow the program’s Exposure Control Plan for disposing cotton balls or swabs that have been used to absorb a patient’s blood. The ADSes and/or acudetox supervisor must check the room for stray needles after each session. ADSes must be able to address adverse clinical situations such as: o Deficiency/weakness: Clients who are extremely “deficient” or weak may need a lighter treatment using seeds or fewer needles. For example, clients who are HIV positive or pregnant or just off a long, hard run of drug use may be weak and more sensitive to the needles. o Fatigue/hunger: Encourage clients who are excessively fatigued to rest and clients who are excessively hungry to eat. Some program supply food. Others explicitly instruct clients to eat a light meal prior to acupuncture treatment. o Broken skin or bruising: When clients have pimples, cuts, sores, rashes, irritation, infection, bruises or hematomas (swelling containing blood), etc. at the point location, do not needle that point until the site has fully National Acupuncture Detoxification Association © NADA 2008 Training Manual Section X: Appendices 144 o o o o o o o healed. If a client has a wart or scar tissue at a point location, likewise do not needle it. Hemophilia: Clients who are hemophiliacs “bleeders” may still be treated even though there is some bleeding possible when needles are removed. Bleeding is minimal because of the minuscule size of the needle hole. It is appropriate to ask such clients about their medication compliance and monitor them more carefully. The same applies to clients on anti-coagulation medications. However, these conditions are not contraindications acudetox. High/intoxicated: Clients who have just used or are still very intoxicated may not get as much benefit from the treatment. Fear of needles (Belanephobia): Clients with fear of needles may need additional support in order to feel safe with the needling process. Allow them to observe or speak with other clients. Breathing exercises and options such as just trying one needle, sitting without needles or using press seeds/balls can be helpful. Hering’s Law of Cure: a theory out of homeopathy in that as the body, mind and spirit clear past trauma, a flare-up might very likely occur. If so, it will happen in the first 24 – 48 hours after treatment, will not last for more than 24 hours and will not be a new symptom. Rather than viewing a symptom as a negative, the client should be instructed to view it as part of his or her healing, that he or she is getting better. If the symptom is new, or one that the client does not remember having before, he or she should be instructed to contact a physician. Needle shock, postural hypotension, vagal reaction, needle sickness or fainting: Although this rarely occurs ADSes must always look for signs immediately after needle insertion. Symptoms include loss of color, sweating, dizziness, lightheaded sensation, nausea and fainting. If a client feels faint or faints while sitting up, calmly remove the needles, raise legs to a horizontal position and lower the head. It is recommended that clients be placed safely on the floor if possible (be sure there are no contaminated needles in the area on which the client will by lying), making sure that the airways are not obstructed. If client feels chilled, help him or her to stay warm. Symptoms resolve quickly and client will exhibit relaxed behavior as if a full treatment occurred. Eating prior to treatment decreases the possibility of needle shock even further. Do not attempt to needle again in the same day. Hematoma (swelling due to bleeding under the skin): May occur when a needle is removed. Have the client apply pressure with a dry cotton ball. Needle through ear: National Acupuncture Detoxification Association © NADA 2008 Training Manual Section X: Appendices 145 May occur on insertion, particular in the liver point. Does not cause problems but may be disconcerting for the client. Adjust depth of needle insertion – review needling technique. o Infection: Rare with proper infection control procedure. Do not needle the infected site until it has healed. Encourage client to clean and apply first aid or refer to medical personnel. o Headache: During treatment (headache that comes on shortly after insertion of needles), remove or loosen sympathetic point. For post treatment headaches, first determine if this was a onetime occurrence or if it has happened several times. If it occurs after several treatments, do not insert the sympathetic point next time. If this does not help then try reducing the length of the treatment session. Minimizing risk to ADSes • • • • • • • Use Universal Precautions and prevent contact with blood and therefore any blood borne pathogens. Wear gloves to cover any open sores/wounds on your hands while needling. Consider gloving hands while removing needles even if the program’s Exposure Control Plan does not require it. Wear closed-toe shoes at all times when needling or are in areas where needles are being or have been inserted. Be mindful. Prepare the room ahead of time. Keep the work areas clean. Put all used needles into a red sharps container. Do not overfill containers. Follow the program’s Exposure Control Plan for disposing cotton balls or swabs that have been used to absorb a patient’s blood. Use extreme care when retrieving fallen needles from surfaces to prevent a needle stick. A magnet, hemostats or tweezers must be used to pick up stray needles. Needles must be removed from a magnet with hemostats or tweezers to prevent needle sticks. Carefully check the room for stray needles after each session. Consider being vaccinated against HBV infection. Be familiar with the program’s Exposure Control Plan and know what to do if there is an inadvertent needles stick or other exposure to blood. Be sure to follow all state and local laws concerning supervision, the types of clients that can be treated, the types of programs in which acudetox can be performed by non-acupuncturist ADSes, treatment documentation, etc. Abide by the ADS Ethics Pledge. Limit acupuncture treatment to the five acudetox points unless otherwise permitted by state or local statutes. Establish and maintain rapport with clients at all times. • • • • • • • Minimizing risk to programs and acudetox supervisors National Acupuncture Detoxification Association © NADA 2008 • Training Manual Section X: Appendices 146 • • • • • • • • Even if not required by state statute, have written agreements in place between the program and supervisor and between the supervisor and ADSes and ADS trainees outlining the responsibilities and duties for which each party is responsible. Assure each client signs an informed consent and any other federal, state and local forms required prior to receiving an acudetox treatment. For clients under the legal age of consent (generally 18 years old), a parent or legal guardian must give consent. In programs where ADS trainees are attaining clinical hours by treating the program’s clients, the informed consent must clearly state that the treatment may be provided by students/trainees. Establish and maintain security and confidentiality of client records, personally identifiable health information and protected health information per federal and state statutes. Assure that clients and ADSes follow the established guidelines as outlined above, particularly those regarding Universal Precautions, ADS-client rapport, and ethics. Develop and implement an Exposure Control Plan per 29 CFR 1910.1030(c). By law input must be solicited from, “non-managerial employees responsible for direct patient care who are potentially exposed to injuries from contaminated sharps” (Office of the Federal Register, 2006: 21 CFR 1910.1030(c)(1)(v)) In acudetox programs this most likely means the ADSes and cleaning personnel. Use only pre-packaged, pre-sterilized, single use needles for acudetox. Have gloves available for use when removing needles even if the program does not mandate their use. Be sure all personnel who may come in contact with blood or be inadvertently stuck with a contaminated needle receive proper training in Universal Precautions and Blood borne Pathogens, are familiar with the Exposure Control Plan and attend annual refresher courses. Have liability insurance protection in place specifically for acudetox. References California Department of Industrial Relations (2001). The Exposure Control Plan for Blood borne Pathogens. CDE Press, California Department of Education. Centers for Disease Control and Prevention (2003). Exposure To Blood. What Healthcare Workers Need to Know. Centers for Disease Control and Prevention (2005). Universal Precautions for Prevention of Transmission of HIV and Other Blood borne Infections Fact Sheet. Congressional Record (2000). Needlestick Safety and Prevention Act. Public Law 106-430, 106th Congress Kailin DC (1997). Acupuncture Risk Management. Corvallis, OR: CMS Press. National Acupuncture Detoxification Association © NADA 2008 Training Manual Section X: Appendices 147 National Acupuncture Foundation (1997) Clean needle technique manual for acupuncturists: guidelines and standards for the clean and safe clinical practice of acupuncture. Washington, DC: National Acupuncture Foundation. Office for Civil Rights (2003). Summary of the HIPPA Privacy Rule. Rockville, MD: Department of Health and Human Services.. Office of Applied Studies (2002). National Survey of Substance Abuse Treatment Services (NSSATS): 2000. Data on Substance Abuse Treatment Facilities. DASIS Series: S-16. DHHS Publication No. (SMA) 02-3668. Rockville, MD. Office of the Federal Register (2006). Code of the Federal Register 29 CFR 1910.1030. Washington, DC: US Government Printing Office Website: http://www.osha.gov/pls/oshaweb/owadisp.show_document?p_table=STANDARDS& p_id=10051 - 1910.1030. Wagner RA (2006). Informed Consent. Retrieved November 10, 2007, from eMedicine Health Website: http://www.emedicinehealth.com/informed_consent/article_em.htm. Special thanks to David Wurzel, LAc for researching and compiling this valuable document. National Acupuncture Detoxification Association © NADA 2008 Appendix “D” Research “D 1” Training Manual Section X: Appendices 148 National Acupuncture Detoxification Association © NADA 2008 Training Manual Section X: Appendices 149 National Acupuncture Detoxification Association © NADA 2008 Training Manual Section X: Appendices 150 National Acupuncture Detoxification Association © NADA 2008 Training Manual Section X: Appendices 151 National Acupuncture Detoxification Association © NADA 2008 “D 2” Training Manual Section X: Appendices 152 National Acupuncture Detoxification Association © NADA 2008 Training Manual Section X: Appendices 153 National Acupuncture Detoxification Association © NADA 2008 Training Manual Section X: Appendices 154 National Acupuncture Detoxification Association © NADA 2008 Training Manual Section X: Appendices 155 National Acupuncture Detoxification Association © NADA 2008 Training Manual Section X: Appendices 156 National Acupuncture Detoxification Association © NADA 2008 Training Manual Section X: Appendices 157 National Acupuncture Detoxification Association © NADA 2008 Training Manual Section X: Appendices 158 National Acupuncture Detoxification Association © NADA 2008 Training Manual Section X: Appendices 159 National Acupuncture Detoxification Association © NADA 2008 “Appendix E” Training Manual Section X: Appendices 160 Excerpts from Treatment Improvement Protocol (TIP) 45 The Center for Substance Abuse Treatment (CSAT) of the Substance Abuse and Mental Health Administration (SAMHSA) of the US Department of Health and Human Services regularly publishes Treatment Improvement Protocol (TIP) manuals for service providers. TIPs are “best practice guidelines for substance abuse disorders” (Center for Substance Abuse Treatment 2006). TIP 45, Detoxification and Substance Abuse Treatment, published in 2006, includes references to the use of acupuncture in programs that provide such services. Following are pertinent excerpts from the TIP (Copies of the entire TIP may be obtained free of charge from SAMHSA’s National Clearinghouse for Alcohol and Drug Information (NCADI), (800) 729-6686 or (301) 468-2600; TDD (for hearing impaired), (800) 487-4889, or electronically through the following Internet World Wide Web site: www.ncadi.samhsa.gov.) Chapter 3—An Overview of Psychosocial and Biomedical Issues During Detoxification Strategies for Engaging and Retaining Patients in Detoxification Consider Alternative Approaches Alternative approaches such as acupuncture are safe, inexpensive, and increasingly popular in both detoxification and substance abuse treatment. Although the effectiveness of alternative treatments in detoxification and treatment has not been validated in well-controlled clinical trials, if an alternative therapy brings patients into detoxification and keeps them there, it may have utility beyond whatever specific therapeutic value it may have (Trachtenberg 2000). Other treatments that reside outside the Western biomedical system, typically grouped together under the heading of Complementary or Alternative Medicine, also may be useful for retaining patients. Indeed, given the great cultural diversity in the United States, other culturally appropriate practices should be considered. (pg. 34) Chapter 4—Physical Detoxification Services for Withdrawal From Specific Substances Alternative Approaches Alternative methods that have been studied scientifically do not claim to be stand-alone withdrawal methods, nor stand-alone treatment modalities. Alternative approaches are designed to be used in a comprehensive, integrated substance abuse treatment system that promotes health and well-being, provides palliative symptom relief, and improves treatment retention. Therefore, because isolation of any of these approaches as an independent variable in rigorous controlled studies is difficult, if not impossible, there are no conclusive data on the effectiveness of alternative methods (Trachtenberg 2000). Auricular (ear) acupuncture has been used throughout the world, beginning in Hong Kong, as an adjunctive treatment during opioid detoxification for about 30 years. Its use in the United States originated in California (Seymour and Smith 1987) and New York (Mitchell 1995) but has not been subjected to rigorous controlled research. One report (Washburn et al. 1993) noted that patients dependent on heroin with mild habits appeared to benefit more than those with severe withdrawal symptoms, which acupuncture did not alleviate. The 1997 National National Acupuncture Detoxification Association © NADA 2008 Training Manual Section X: Appendices 161 Institute of Health Consensus Statement on acupuncture stated that acupuncture treatment for addictions could be part of a comprehensive management program. The National Acupuncture Detoxification Association has developed acupuncture protocols involving ear acupuncture in group settings that originated at Lincoln Hospital in the Bronx and are used by over 400 drug treatment programs and 40 percent of drug courts. SAMHSA’s National Survey of Substance Abuse Treatment Services (NSSATS) found that 5.4 percent of the 13,720 facilities polled in 2001 offered acupuncture as a service (Office of Applied Studies 2002 b). Acupuncture is one of the more widely used alternative therapies within the context of addictions and behavioral health treatment. It has been used as an adjunct to conventional treatment because it seems to reduce the craving for a variety of substances of abuse and appears to contribute to improved treatment retention rates. In particular, acupuncture has been viewed as an effective adjunct to treatment for alcohol and cocaine disorders, and it also has played an important role in opioid treatment (i.e., methadone maintenance). It is used as an adjunct during maintenance, such as when tapering methadone doses. The ritualistic aspect of the practice of acupuncture as part of a comprehensive treatment program provides a stable, comfortable, and consistent environment in which the client can actively participate. As a result, acupuncture enhances the client’s sense of engagement in the treatment process. This may, in part, account for reported improvements in treatment retention (Boucher et al. 2003). A 1999 CSAT-funded study showed that patients choosing outpatient programs with acupuncture were less likely to relapse in the 6 months following discharge than were patients who had chosen residential programs (Shwartz et al. 1999). Ear acupuncture detoxification, which was originally developed as an alternative treatment for opioid agonist pharmacotherapy, is now augmenting pharmacotherapy treatment for patients with coexisting cocaine problems (Avants et al. 2000). The advocates of acupuncture have joined with the advocates of opioid agonist pharmacotherapy to create a holistic synthesis. Each has contributed to the success of the other, both clinically and in public perception. Care must be taken to ensure sterile acupuncture needles in the heroin-dependent population, given the high incidence of HIV infection, viral hepatitis, and other infections. Acupuncture is not recommended as a standalone treatment for opioid withdrawal. Other alternative management approaches that are not supported by controlled studies include neuroelectric therapy (the administration of electric current through the skin) and herbal therapy. In fact, the former has been shown to be no better than placebo in a controlled study (Gariti et al. 1992). The use of herbs for healing purposes dates back to the dawn of civilization, while the use of herbs in the treatment of substance abuse has been documented since 1981 in methadone programs, free clinics, therapeutic communities, outpatient programs, and hospitals (Nebelkopf 1981). Herbal remedies are used in substance abuse detoxification and treatment in a number of cultures around the world. However, in no scientific studies have herbs been isolated as a discrete variable to test their efficacy. Much research is currently being conducted on the effectiveness of herbal medicine on a wide variety of physical conditions. (pgs. 103-104) Considerations for Specific Populations People With Disabilities or Co-Occurring Conditions National Acupuncture Detoxification Association © NADA 2008 Training Manual Section X: Appendices 162 There are a number of alternative treatments for chronic pain. Acupuncture is already in use in some treatment programs for detoxification to help relieve symptoms of withdrawal. Physical therapy and exercise, chiropractic care, biofeedback, hypnotism, and therapeutic heat or cold are some other approaches to caring for persons with physical problems. Most of these alternative treatments have limited or no research support of their efficacy; yet some clinicians believe they work. Thus, consultation with experts on their use is necessary before starting a person with chronic pain on these remedies. (pg. 113) National Acupuncture Detoxification Association © NADA 2008 Training Manual Section X: Appendices 163 Appendix “F” Special Populations - Women Lincoln Recovery Maternal Substance Abuse Services – Raising Healthy Babies In October of 1986 staff at Lincoln Recovery noted an obvious increase in the number of women attending the program, primarily for “crack” addiction. A women’s contingent was implemented in order to relate exclusively to women’s issues. The six-week program was designed to be convenient, attractive to women and “workable”. A 10-day mandatory detox period, with no unrealistic excused absences, is the initial phase of the program. Women are expected to call in if they are unable to appear due to court appearances or other accountable reasons for missing. The clients receive acudetox; have daily urinalysis and crisis counseling. The staff notes that in depth counseling during the first 10 days in inadvisable, and instead provides that time frame as an acclimation period for clients to become comfortable with the clinical setting and receiving acudetox. Women are responsible for connecting with a counselor following the 10 day detox phase. The program specifically does not chase clients or try to coerce them into treatment or providing urine specimens. Noting that many support systems have a way of making women “act like children”, the staff encourages women to work the program from a perspective of autonomy and responsibility, especially since many of them have children of their own to raise. Results of the urinalysis profiles determine the phases of progress through the program. A report of all clean urines results in a time commitment decrease to twice per week. If there are some positive urinalysis results, the counselor works with the client to set up a schedule and design the treatment process according to the situation and needs of the client. The women are required to take acudetox and leave a urine specimen at each treatment visit. Crisis counseling often plays a large role in the treatment plan. The Child Welfare Administration is responsible for approximately 80% of the treatment referrals to the women’s program. Because of that agency’s participation, some of the women stay in the program for as long as 6 months. The longer time frame allows for better monitoring and supports a stronger recovery. The agency’s relationship with Lincoln Recovery is mutually cooperative and successful recovery often results in the women having their children returned to family custody. Program Design Lincoln Recovery’s Maternal Substance Abuse Program takes walk-in clients and provides on-demand treatment services. Although there are appointments given for intake, the women are encouraged to do daily acudetox/urinalysis, even during the time prior to the completion of their intake appointment. Each client must attend orientation classes, which are available each morning to facilitate participation. Narcotics Anonymous meetings are held daily. The Women’s Narcotics Anonymous meeting is mandatory, and attendance is taken with a six-session requirement. The Women’s Rap Group is also National Acupuncture Detoxification Association © NADA 2008 Training Manual Section X: Appendices 164 mandatory and offered weekly. A wide range of issues are discussed, including safe sex, AIDS, etc. The women must attend six sessions in order to complete this phase of their treatment program. Time commitments are considered within the treatment design. From start to finish, the acudetox session may take approximately one hour. Additional interactions, such as counseling sessions may add up to about two hours of total program time for each visit. Women are allowed to bring their children with them to the program, and a hands-on parenting skills program helps increase their abilities. There is a non-judgmental atmosphere, which allows the women to realize that the program staff is sincere in their commitment to support progress. Recovery tends to be successful in this kind of supportive atmosphere. Women may repeat the program if they are not successful in maintaining sobriety. Lincoln Recovery was the first drug treatment program to offer a prenatal clinic, with a midwife available one day per week. Prenatal education is provided and referrals made when necessary. Educational videos regarding safe sex, AIDS, pregnancy and other topics are shown daily. Prenatal clients are required to attend acudetox twice weekly until they deliver. Early statistics showed an average of 65-70% clean urinalysis results after three months of treatment. Women often have specific challenges in getting to and maintaining treatment. Addressing their issues and allowing for easy access to treatment has shown an increase in treatment compliance. National Acupuncture Detoxification Association © NADA 2008 Training Manual Section X: Appendices 165 Appendix “F 2”: Special Populations – ADD/ADHD Dustin’s Story The following is a story of one mother, her search for treatment and her success with acupuncture: I am a nurse and an Acupuncture Detoxification Specialist. My husband and I have three sons, James 17, Dustin 15, and Douglas 6. My husband and I grew up on farms in the Midwest and remained in the area until 1996. Then our lives changed. My husband was offered a job with a competing firm, and we chose to move closer to the metropolitan area. Our main concern with relocation was our children’s education, mainly for our middle son, Dustin. At six months of age, we knew Dustin was delayed and began taking him to the best doctors in the state. Many times we traveled 150 miles to the University Hospital. During a period of several months and after several trips, which took three hours each way, we were told Dustin would never walk or talk. With occupational therapy and a lot of hard work, Dustin was walking unaided at age 20 months. At age four, after repeated trips to the doctors for tonsillitis and ear infections, he had a tonsillectomy and adenoidectomy which helped him to breathe and talk more clearly. Again with occupational therapy, his vocabulary increased. However, he was an angry child, always on the go, destroying anything in his way and making family life unbearable. Then, we were referred for physical and psychological testing for our son. We were willing to do whatever it took to help him. He hated to be touched, had verbal outburst, had no sense of danger and an attention span of less than five seconds. Our first appointment was at 8:00 a.m. After a two hour trip, we waited in the waiting room for another two hours. By the time we say the doctor, we were all hungry, tired and angry. After one hour of testing, Dustin was put on 30 mg. per day of Ritalin at four years of age! Many old problems disappeared. Now, we had a child who did a lot of sitting and not much of anything else. He was still very angry and when the medication wore off in the evening, he was goring himself with food, restless, tearful and unable to sleep. Of course, we sought alternatives. We did allergy testing. He was put on a special diet and had injections. There was no improvement but a lot of work. Every physician we saw sent us to someone else. So more and more medication and treatments were added according to whatever their specialty was. When Dustin began school, a whole new set of problems developed. We discovered our educational system for children with disabilities is virtually nonexistent in some areas. The main goal of the school for Dustin was for him to sit in the back of the class and remain quiet. Well, the medication sure did that. Year after year was a battle. We wanted him to be educated. They wanted him out of the way. Then we relocated. This was a hard decision for us. We had to leave the only home we’d known, friends and family, and seek a school we thought would be beneficial. When Dustin began 8th grade his curriculum was modified to his level and increased at his pace. Still, the teachers kept saying he was tired and withdrawn from the other children. We felt it was due to the Dexedrine he’d been switched to after a bout of depression he’d experienced two years prior to our move. That’s when Lithium and Catapres came into the picture. National Acupuncture Detoxification Association © NADA 2008 Training Manual Section X: Appendices 166 In November of 1996, I accepted a job as a Detox Nurse in a small, rural town. Only having prior experience with medical/surgical and geriatric nursing, I felt I had a lot to learn. As the months went by, I saw withdrawal constantly on the job and when I got home, I saw my son going through withdrawal every night. They were so similar that it was obvious to me why my son was so tired, withdrawn and subservient all day and just the opposite at night. In May, I volunteered to attend acupuncture training to help with withdrawal symptoms in detox. I came home and practiced on my family so I could perfect my technique before taking the test. Something totally unexpected happened. Dustin fell asleep during the treatment after about 5 – 10 minutes. I spoke to our family physician and our company physician and was encouraged to continue and to document. With each treatment, it was the same. I even did a treatment on him while friends were visiting and Dustin was very hyper. Again, he began to relax and settle down. Our friends were amazed, as were we. Dustin began to ask for the treatment in the evening. So, I began regular auricular acupuncture treatment using the five points I had learned. My son was taking Catapres 0.1 mg. twice per day, Lithium 950 mg. daily and Dexedrine 40 mg. daily. We did treatment one time per day for the first week; then, two times per week for one week with seeds on at all the other times; then one time per week for one week with seeds in-between placed on the same spots of the ear to provide sustained acupressure. The Vaccaria seeds stimulate the area because they cause a mild irritation. They generally go unnoticed and can be left in place, held on by surgical tape, for 3 to 5 days. Dustin’s blood pressure was reduced enough to discontinue the Catapres slowly over two weeks’ time. The depression subsided almost immediately with needling and the Lithium was discontinued over a period of two weeks also. The Dexedrine was reduced slowly over a period of one month with a teacher’s response being – handwriting improved, self-esteem increased, more alert and sociable. He now takes 10 mg. tablets of Dexedrine at 6:30 a.m. which he asks for, stating, “It helps me in the morning.” So that he will not be hungry, we are working out a snack midmorning and reducing the Dexedrine. His weight has increased, some of which is normal for him when school begins. His blood pressure is 130/86 and there are no signs or symptoms of depression. His sleep pattern is greatly improved along with his self care and he has made friends in his school without teacher or parent intervention. His grades are equal or better compared to last year. I can definitely say the tone of our household is 80% improved due to his better behavior. His is more alert and has a fantastic personality and sense of humor. There are no more angry outbursts and less destruction of property. The family is much closer after the use of acupuncture because there is a sense of calm we have not experienced in fifteen years since he was born. We were always “waiting for the next storm” or problem to arise. He was always the center of attention. Periodically he will ask for a treatment or seeds in his ears when he has trouble sleeping. I will continue to needle him on an as-needed basis to maintain him at this level. He is a much happier child since beginning acupuncture. Now, he is not scolded constantly or punished because of his behavior – he is accepted and enjoyed. We feel we have finally unleashed his true personality – not a drug induced one. He has been on medication since he was four years of age and that’s okay because that is all we had access to. Someday he may need medication again, but for now it is working and we are all benefiting. National Acupuncture Detoxification Association © NADA 2008 Training Manual Section X: Appendices 167 Appendix “F 3”: Special Populations – ADD/ADHD The Reed Academy Experience (NADA Conference, March 8, 2003, Washington, DC, Michael Smith) - the use of gold magnetic beads in the treatment of boys with ADHD, bipolar and Asperger’s syndrome Reed Academy is a widely acclaimed residential school for boys with serious behavioral health problems. Under the supervision of Dr. Ed Cohen, director of Reed Academy, and Mary “Penny” Mortensen LPN, the Reed school nurse, Christine Lee, RNCS, Lic. Ac., and Janine Agoglia conducted a 6 week pilot study using one gold magnetic bead placed in the posterior shenmen position on each ear. The project was suggested by Dr. Michael Smith of Lincoln Hospital (Bronx, NY) who has previous experience with this type of treatment. The beads provide an acupuncture-like effect. The following data summarizes the response of all 13 boys in the study. The name, age, diagnosis, test response, and clinical response are listed. Test response is based on a modified Conners test which has 12 items which were graded from 0 to 3 in order of severity. The first number represents the score at the beginning of the study as reported by teachers, nurse, parents and child care workers. The second number is the score recorded at the end of the 6 week period. Most of the boys are on several medications. Medications were not changed during the study. Case-1 (age 13) PTSD, conduct disorder (20-15) – improved relationships; less fidgeting; did better than his score indicates because he was noted to deliberately behave poorly while being observed. Due to his previous history, Case-1 enjoyed the negative attention. Case-2 (age 15) ADD, PDD (21-6) – greatly reduced excess movement and impulsive behavior; improved concentration; better at relationships; “I no longer feel the high energy that made me move all the time”; Case-2 asked to continue wearing the beads after the study was completed and still wears them 1 year later; his mother has felt unable to handle her son at home for the past 6 years, now she feels confident to have her son return home. Case-3 (age 14) Aspergers, non-verbal learning disorder (20-13) – has improved slowly over time; was able to listen and think more carefully; less fidgeting; finally able to “dismantle” part of his fantasy world. Case-4 (age 14) ADHD, ODD (22-11) – definitely less fidgeting; parents note improvement. More cooperative on the weekends; able to work on craft projects using electric tools without fear by parents of intentional self injuries. Case-5 (age 13) bipolar, borderline MR (18-17) – more verbal; little change noted. Case-6 (age 13) PTSD, ADHD, PDD, attachment disorder (28-23) – less fidgeting, better organizing; little change. Case-7 (age 13) ADHD, bipolar, Asperger, tricolomania (21-10) – less fidgeting; stopped pulling his hair almost immediately and retains a full head of hair, eyelashes, and eyebrows a year later. National Acupuncture Detoxification Association © NADA 2008 Training Manual Section X: Appendices 168 Case-8 (age 11) ADHD, bipolar, anxiety (22-11) – communicates better with parents; is able to go out with family without causing a scene; less acting out in class; less running and climbing. Case-9 (age 11) bipolar, excess control needs (17-7) – mother finds him more relaxed; communicates better; Case-9 felt like “beads were in control” and dropped out of the study after four weeks; nevertheless the improvement continued. Case-10 (age 10) bipolar, Aspergers, ADHD, borderline MR (20-18) – more in touch with feelings; more warm; better at relationships and sticking to activities. Case-11 (age15) ADHD, bipolar, introvert, very depressed (no score) – finally able to divulge sensitive material; Case-11 dropped out after 4 weeks because he felt the “beads were controlling him”; nevertheless the improvement continued; he is now doing well in a more main stream school. Case-12 (age 14) bipolar, PTSD, schizoid, ADHD (no score) – rapid improvement in anger management and constant hair twirling; dropped out because he transferred to a more mainstream school where he is doing well; Case-12 was started on a new experimental medication during the study period. Case-13 (age 13) PTSD, OCD, ADHD, schizoid (no score) – dropped out in the middle of the study because he felt a “loss of control”; nevertheless he has handled difficult family turmoil much better than was to be expected. Most of the boys seemed to have had a significant sustained improvement as a result of the bead use. Reed Academy has a capacity of 25 students. All parents were offered the opportunity for this study. Fourteen gave consent. Nine completed the study, although it seems clear that several of the drop outs also had a significant experience. The option was given to the parents to also wear the beads while their sons were in the study, six parents wore them for three (3) weeks and each noted a difference in how they managed their own stress. Acupressure treatment such as this protocol helps a person help himself. It is an adjunctive treatment that seems to help the patient tap into a reserve capability for balance and rejuvenation. Similar treatments are used widely for addiction, traumatic stress, and serious mental illness. This treatment seems to enhance other psycho-social components so that these treatment effects might be more evident in a high quality supportive environment such as Reed Academy. The beneficial effects of the bead treatment seemed to begin within the first week of treatment. These effects often continue for years later even though the beads may be used for six weeks only. The bead treatment seems to initiate a reparative process that does not necessarily need prolonged stimulation to be effective. Joanne Lenny, a Lincoln Hospital volunteer, has shared with us two remarkable success stories (one with congenital nystagmus and the other a three year old with autism) in which several weeks’ bead treatment led to seemingly permanent improvement. We did not expect these results. Clearly there is a great deal to learn about the reliability and significance of these pilot study findings. Our purpose is to share these tentative results. To learn about this treatment in general contact Michael Smith at Lincoln Hospital, 718-993-3100, x 113. To learn about this pilot study contact Christine Lee at 508-596-4680. Mary (Penny) Mortenson of Reed Academy, 508-877-1222, coordinated this study and provided the clinical insight about these boys that has been so valuable to us. National Acupuncture Detoxification Association © NADA 2008 Training Manual Section X: Appendices 169 Appendix “F 4”: Acudetox: Beneficial Effects Beyond Detox Laura Cooley, L.Ac. 22 Forrest Tallman Rd, Orford, NH 03777 603 353 9893 email
[email protected] Acupuncture has been employed since 1978 as an adjunct treatment for Substance Use Disorder in some 700 Drug Treatment facilities around the world. The specific acupuncture treatment found most effective is the NADA (National Acupuncture Detoxification Association) 5 point protocol, consisting of 5 needles placed in each ear at specific points. This 5 point protocol has been found to reduce cravings and reduce recidivism of substance abuse*. It is important to provide the body of knowledge that has also developed as a result of the implementation of this treatment. What follows is a review of recent studies, outcome data, client surveys, and collected information on effects noted to accompany the reduced cravings and recidivism which are not yet in the literature. One study involves full body acupuncture and has been included to show that the outcomes support what clients receiving the NADA protocol report through client surveys. Each of these examples have unique aspects that contribute to the picture of potential results of this treatment for a variety of populations. * A synopsis of studies and published articles available at end of review. Acupuncture and Acu detox have been used in a variety of treatment settings for a range of presenting problems including: Substance Use Disorder, Relapse Prevention, ADD, ADHD, Depression, Anxiety, HIV and HIV prevention, sexual offenders and juvenile offenders. Results have shown that participants experience less anxiety, depression, insomnia, increased concentration, a reduction in anger and violent outbursts, reduced need for medication, and stabilization of emotional and mental processes of the mentally ill. This is in addition to the already documented effects of reduced cravings and withdrawal symptoms, greater rates of program compliance and completion, lower recidivism and longer periods of sustained sobriety. The reduction of anxiety, depression, insomnia and concentration demonstrated would suggest that Acu detox would offer important benefits for anyone suffering from post traumatic stress disorder, such as victims of violent crime, natural disasters, etc. The dramatic reduction in violence among historically dangerous offenders makes a strong statement recommending Acu detox as a treatment of choice to reduce violence within criminal justice facilities, and for domestic violence offenders, sexual offenders, parents found to be abusive to their children or anyone with a tendency towards violence and poor impulse control. The potential for stabilizing those living with ADD, some of whom who may also be presenting violence and substance use disorder, may be quite high. It is also an effective tool for those who do not seem to benefit from verbal methods of drug counseling, such as the mentally retarded or others who have low verbal skills. It appears that some of the most difficult factors which prevent effective treatment for substance abuse, dual diagnosis, violent and sexual offenders, non compliance and resistance, leaving treatment AMA (against medical advice), high levels of anxiety and fear, depression and lack of motivation, physical debility (due to drug use or withdrawal), mental and emotional instability, inability to concentrate and retain material, are addressed by this treatment. National Acupuncture Detoxification Association © NADA 2008 Training Manual Section X: Appendices 170 In light of the fact that Acu detox is ineffective outside of a drug treatment program and counseling, it may be that using Acu detox along with psychotherapy could yield more significant results for treatment of depression. The effectiveness of pharmacological and psychotherapeutic interventions for depression do not last, but it is possible that using Acu detox with psychotherapy would yield more sustained relief, without the expense and the considerable side effects of pharmaceuticals, this could provide a more inexpensive, more effective and less intrusive form of treatment for depression. Since all manner of health care professionals can easily, safely and cheaply be trained to provide this service within their scope of practice, integration into the public health care system could realistically be obtained. This treatment lends itself well to the multidisciplinary treatment team approach that we know is necessary to address the complexity of issues involved in, for example, dual diagnosis, and would support the models of prevention and integrated treatment being proposed by federal and state levels of government**. All members of the treatment team can be trained to deliver the treatment protocol, leading to the ”barrier free” access to service necessary to obtain high levels of effectiveness. It provides a useful tool that de-escalates crisis situations, that can be used on crisis intervention units (Psychiatric Facilities) or travel to where the crisis is occurring (Street Outreach Programs). One last mention of the NADA protocol is that staff also receive treatment. This enables staff to receive all the benefits that clients also receive and helps to build more efficiency into the systems providing care. In an arena where professionals, who bring with them a variety of disciplines and educational backgrounds, are now having to work together, it provides common ground on which to build bridges. It may be that this could be one of it’s most important and powerful functions. **Crime-What Works, What Doesn’t, What’s Promising. A report to the United States Congress, prepared for the National Institute of Justice; available @ web site: http://www.ncjrs.org/works/index.htm) Anxiety & Depression Department of Psychology, University of Arizona John J. B. Allen, Ph.D. (520) 621 0992 The Efficacy of Acupuncture in the Treatment of Major Depression in Women The University of Arizona conducted a 2-year study on the effect of acupuncture on major depression and found 70% of subjects remitted with 64% experiencing full remission of major depression. This is roughly the same success rate as pharmacologic and psychotherapeutic treatments, which is an important finding, since both pharmacology and psychotherapeutic interventions fail to provide lasting relief. It is estimated that 17% of the US population suffers from major depression. The costs of treatment exceed those of other chronic illness such as diabetes or hypertension in terms of personal distress, lost productivity, interpersonal problems and suicide. Patients were included if they met DSM-IV diagnostic criteria for current Major Depression. To assess the women’s depression, a modified version of the Hamilton Rating Scale for Depression was used. Resting EEG was assessed every 8 weeks during the acupuncture treatment. Treatment National Acupuncture Detoxification Association © NADA 2008 Training Manual Section X: Appendices 171 performed was full body acupuncture, not the 5 point Acu detox protocol, but findings are consistent with what Acu detox clients report. British Columbia Women’s Hospital, Aurora Centre Nancy Poole, Principle Investigator (604) 875 2066 Evaluation Results Regarding Provision of Acupuncture as a Complementary Therapy for Women in Addictions Treatment This study, performed in a residential treatment center, found that clients who received Acudetox experienced a greater reduction in anxiety, depression, insomnia and concentration difficulties than clients in the same group who did not receive Acu detox. Sacred Heart Rehabilitation Center, Inc. Memphis, Michigan Opiate Detox and Stabilization Program (Inpatient Rehabilitation Facility) Joyce Hartsfield, D.O. (810) 392 2167 According to a client survey administered over an 11 month period to clients receiving the 5 point NADA protocol on average 7-10 treatments: 56% reported less anxiety 50% reported less depression 53% reported less insomnia Doctors Hospital in Toronto Tyrone Turner, M.D., Medical Director of Mental Health Services at Doctor’s Hospital in Toronto (416) 530 6788 Pilot Project Study - Acupuncture for Women with Addictions A Pilot Project Study in 1995-96 was conducted at Doctors Hospital in Toronto. Over the course of 20 weeks clients were assessed at intake, completed 6 client self-report questionnaires, Service Utilization Questionnaire, Client Well-Being Questionnaire, Client Satisfaction Questionnaire, and measures were taken using Centre for Epidemiologic Studies Depression Scale (CES-D) and Drug Avoidance SelfEfficacy Scale (DASES). The Pilot Project Study found that the Acu detox treatment significantly reduced depression and anxiety, improved sleep and contributed to improvements in perceived well-being. The changes in these conditions are also reflected by reduction in the frequency of use of most health and social services. Reduced use of substances was another result. A cross over study design with randomization of clients was employed. Criminal Justice & Violence Dartmoor Prison, United Kingdom Alan Dudley, Principal Officer Margaret Pinnington, NADA Trainer 011-44-1202-398-460 National Acupuncture Detoxification Association © NADA 2008 Presented at UK NADA Conference 1998 by Alan Dudley Training Manual Section X: Appendices 172 Acu detox programs were initiated at Dartmoor prison in May of 1997. Statistics were gathered from two cycles of a series of treatments. Inmates received 4 weeks of Acu detox treatments 5 x’s per week. The Acu detox group was comprised of 75 inmates; the non Acu detox group, 115 inmates. In the Acu detox group, 61 of 75 completed the recommended series of treatments, with those who dropped out receiving only one or two treatments. Treatment group (75 inmates) 1rst cycle intra prison charges positive for drugs 2nd cycle intra prison charges positive for drugs Non treatment group (115 inmates) 4 1 31 11 1 0 12 3 All inmates engaged in Acu detox treatment were administered psych evaluations before and after treatment series and showed positive change. During the 2nd cycle of treatments, all persons on the unit showed improvement. Roz Yates, RN from Elmley prison, primary site in Kent, reports that 1 year after initiating a methadone treatment program, only 1 person has joined the program and all other inmates at Elmley have utilized Acu detox. All 11 prisons in Kent are utilizing Acu detox and prison officials note a decrease in staff absenteeism. Acu detox is currently being utilized in 2/3’s of the prisons in the UK. San Francisco County Jail George Jurand, RSVP Program Manager, County Jail #7, (650) 266 9339 The San Francisco County Jail has set up a special violent prisoner unit. The RSVP program (For Resolve to Stop the Violence Project) is the first mandated, in jail, restorative justice project in the country. James Gilligan, MD, director of the Harvard University Medical School’s Center on Violence has begun a formal, three year evaluation. To date, 700-900 violent offenders have passed through the program with 300 staying for 30 days or more. A scuffle was reported in September of 1997, but no fights have been reported since. Program administrator Sunny Schwartz reports that among the general jail population, fights occur about 3 times per week. Santa Clara County Department of Corrections Prepared by Charlie Savoca, L.Ac. and Cally Haber, L. Ac. 408 479 3760 Evaluation Summary of Acupuncture Program National Acupuncture Detoxification Association © NADA 2008 Training Manual Section X: Appendices 173 Female inmates at Correctional Center for Women, Milpitas, California Santa Clara County Department of Corrections evaluated, among other things, the effect Acu detox treatments had on fear/paranoia, anger/resentfulness, anxiety, depression, and over-reaction in inmates. All of the categories evaluated were reported to have been reduced in frequency among inmates who received Acu detox. Denver County Jail, Project Recovery, Mile High Council J. Oliva, Division Chief, Denver Sheriff Dept., County Jail Division John Simonet, Director of Corrections and Undersheriff Flavia Henderson, Executive Director of Mile High Council on Alcoholism and Drug Abuse, (303) 825 8113 In surveys of inmates who were given the Acu detox protocol, 53% reported better health and attitude, and for those who received 5 or more Acu detox treatments, no Class I and II violations (fighting and assault) were filed. Sexual Offenders Minnesota Corrections Facility, maximum security at Oak Park Heights Pat Culliton, L.Ac. (612) 347 8559 Linda Leef, L. Ac., has been performing acupuncture treatment at a maximum security prison in a treatment program for sexual offenders and addictions. She has recorded through client surveys a reduction in their levels of anger, stress, intrusive sexual fantasies, and compulsive masturbation. Data evaluation in progress. Bob Fulton from The Meadows in Arizona found that when using acu detox with sexual addicts, the “detox” from compulsive sexual behavior is virtually is identical drug detox. Ben Wharton of Sweetwater, Texas has a 3 year sexual offender program and finds that it is as helpful for sexual offenders as with his addiction clientele, and specifically that it breaks the denial sexual offenders most often claim regarding their offenses. ADD/ADHD Case History Cindy Briolet, Detox Nurse, Acupuncture Detoxification Specialist (810) 392 2167 Sacred Heart Rehabilitation Center, Memphis, Michigan Cindy Briolet has a 14-year-old son, Dustin, who was diagnosed with ADD and put on Ritalin at the age of four. He continued to take medications and more recently was prescribed Catapres, Dexadrine and Lithium for ADD and depression. When Cindy Briolet was trained in Acu detox in 1996, she administered needles on her son as practice of the technique. An unusual thing happened: Dustin fell asleep. With repeated treatments, he not only continued to fall asleep, but he began to relax in general. Dustin began to request treatments. Needles in the ear were supplemented by taping small pellets onto the ear to continue stimulation of the ear points between treatments. In November 1997, Dustin stopped taking all medications by his own request, and his depression, sleeplessness and high blood National Acupuncture Detoxification Association © NADA 2008 Training Manual Section X: Appendices 174 pressure no longer exist. His personal hygiene has improved and he no longer has angry outbursts. He states “I feel calm, Mom, and I never feel calm”. This has led to several pilot programs now underway in Michigan, Virginia and the Bronx Virginia Commonwealth University Neil A. Sonenklar, Principal Investigator through the National Institute of Health (Office of Alternative Medicine) Acupuncture Point Treatment for Attention Deficit Hyperactivity Disorder available @ web site; http://altmed.od.nih.gov/nccam/cgibin/research/search_advanced2.cgi#R21RR09463 Approximately 3 to 10% of school age children have ADHD. The usual treatment is the prescription of stimulant drugs. Twenty five% of these children do not respond to this form of therapy and there has been very limited progress in terms of the use of behavioral treatments for ADHD. This study was designed to evaluate the effectiveness of placing a gold bead on one acupuncture point on the ear. Seven children with a primary diagnosis of ADHD based on DSM-III-R criteria took part in this double-blinded placebo control study with themselves as their own controls using a multiple baseline design. The Conners Parent Scale, revised from the Conners Teacher Rating scale, was used as the main outcome measure. Results: 3 children showed improvement during treatment phase 1 showed improvement during placebo phase which continued into treatment phase 2 showed a worsening throughout experimental conditions 1 showed no change in formal data It appears that this treatment is effective for some children with ADHD with minimal risk involved. The results obtained in the previous (above) case study were obtained using first the NADA 5 point protocol, and then switching to the gold pellet application. It is quite possible that significantly better results could be obtained by first administering the Acu detox treatment followed by application of gold pellets, and should be investigated further. Dual Diagnosis Heart of Texas Region MHMR (Mental Health Mental Retardation)Center Tom Atwood, LMSW, Caseworker Supervisor (254) 939 2915 Clients of this program are the most seriously affected by mental illness as indicated by repeated, frequent hospitalizations, repeated arrests or community complaints to law enforcement officials, and the inability to access needed social and treatment programs without continual assistance. A high number also exhibit addictions to various substances. Soon after ear acupuncture treatments began, staff, clients and family members noticed better sleep, reduced stress, better appetite, feeling more relaxed, clearer mind and more energy. Over time, hospital admissions were reduced by 70% from the number of admissions for the previous 3 years. National Acupuncture Detoxification Association © NADA 2008 Training Manual Section X: Appendices 175 A second group was formed from clients living at Lake Creek, a residential halfway house. Hospital admissions were reduced by 80% from the rate of the previous 3 years. A third group was created of clients who were presenting for crisis treatment, exhibiting acute and/or escalating psychiatric symptoms, often leading to hospitalization. This group reduced its hospital admissions from 8 per month for the previous 3 years, to 8 for the first 3 months of the program. Due to external circumstances, this delivery of ear acupuncture was terminated. Caseworkers Gloria Turley and Glenda Hamilton did follow up tracking on the Lake Creek group by surveying client information for the year prior to and the three years following delivery of Acu detox services. Gains achieved with Acu detox were maintained on average of 3 - 6 months after discontinuation of service. Admissions: In the year prior to Acu detox services, 100% of the patients had been admitted to the psychiatric crisis stabilization unit (CSU) at least once per quarter. During Acu detox delivery there were no long term care admissions to CSU, only one short term admission lasting for 2 days***, and after treatment was discontinued, more than half had been admitted. There were 8 admissions for emergency community hospital placement (usually followed by time in the Austin State Hospital) in the year preceding Acu detox, none during the treatment period, and six patients requiring that level of care in the period after. During the period of Acu detox there no admissions to the Austin State Hospital. Once treatment stopped, admissions resumed after Acu detox stopped. Crisis Intervention: The average weekly number of crisis interventions, which had dropped by two thirds, returned to its original level of 3.5 per week. Medications: The review found that one half the patients increased medications two weeks after Acu detox stopped. One month afterwards, all patients had increased their medications. *** personal communication with Gloria Turley, Social Worker, MHMR Retention Rates Betty Ford Center Gail N. Schultz, M.D., Medical Director 800 392 7540 Betty Ford Center conducted a 6-month pilot study with inpatient heroin addicts. Administering the NADA 5 point protocol resulted in a reduction of clients leaving Against Medical advice by approximately 1/3****. This reduction was consistent over the average course of a 28-day stay. **** Rate reduction obtained through personal communication with Dr. Schultz. National Acupuncture Detoxification Association © NADA 2008 Kent/Sussex Detoxification Center, Delaware Irene Rust (302) 422 8338 Training Manual Section X: Appendices 176 The Kent/Sussex Detoxification Center is a state agency that serves all 3 counties in Delaware and 9 counties in the state of Maryland as public detox for indigenous and non insurance carrying clients. Outcome data is presented on 667 consumers who were eligible to participate, 89 % of whom received acupuncture. Of those who received acupuncture; 82% had continued sobriety at 3 months compared to 33% of non acupuncture consumers 87% were not readmitted to detox compared with 18% of the control group and 76% reported an improved quality of life, compared to 34% of the control group. Leaving the program “Against Medical Advice” dropped from pre Acu detox program rate of 16.6 per month, to 9.8 per month. Conclusion The effects of the Acu detox treatment appear to be broad and far-reaching, making it an ideal tool for addressing a multitude of interrelated societal problems. Further research and data collection are necessary in order to educate agencies and policy makers, and to understand exactly how to effectively employ this technique to the most positive benefit. Bibliography Bullock, M.L., Culliton, P.D., & Olander, R.T. (1989, June 24). Controlled trial of acupuncture for severe recidivistic alcoholism. The Lancet, 1435-439. Brumbaugh, A.G., (1993) Acupuncture: New Perspectives in Chemical Dependency Treatment. Journal of Substance Abuse Treatment, Vol. 10, pp.35-43. Konefal, J. (1994) The Impact of the Addition of an Acu detox Program to an Existing Metro-Dade County Outpatient Substance Abuse Treatment Facility. Journal of Addictive Diseases, Vol. 13, #3, pg 71. Smith, M.O., M.D., (1998) Acupuncture in Addiction Treatment. Medical and Health Annual, Encyclopedia Brittannica, Inc. National Acupuncture Detoxification Association © NADA 2008 Training Manual Section X: Appendices 177 National Acupuncture Detoxification Association © NADA 2008 Training Manual Section X: Appendices 178 Appendix “G 1” Sample Program Forms: Confidentiality of Client Records Federal Laws* and Regulations** protect the confidentiality of patient/client records maintained by this program. No information regarding program participation or other data may be disclosed to any person for whom express permission has not been granted via one or more of the following means: • Consent in writing. • Disclosure is allowed by court order. • Disclosure is made to medical personnel during a medical emergency or to qualified personnel for research, audit or program evaluation. Violation of the Federal Laws and Regulations by a program is a crime. Suspected violations may be reported to appropriate authorities in accordance with Federal Regulations. Federal Laws and Regulations do not protect any information about a crime committed by a patient/client either while in attendance of the program or against any person who works for the program or about any threat to commit such a crime. Federal Laws and Regulations do not protect information about suspected abuse or neglect from being reported under State law to appropriate State or local authorities. As a healthcare provider, the program is also required to maintain and use healthcare information as defined in the Privacy Rule of the Administrative Simplification provisions of the Health Insurance Portability and Accountability Act of 1996. A copy of the program’s Notice of Privacy Practices is provided and available. I have read, or have had read to me, and understand the foregoing pertaining to the confidentiality of my treatment/participation records maintained by this program and have been provided with a copy of the program’s Notice of Privacy Practices. Any comments I may have or requests to restrict disclosures of my healthcare/participation information are as stated below: __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ ___________________________________ Client/Participant Name ________________________________ Social Security or other I.D. number ___________________________________ Client/Participant Signature ______________________ Date ___________________________________ Witness Signature *Federal Laws: 42 USC 290dd-3; 42 USC 290ee-3 **Federal Regulations: 42 CFR Part 2 ______________________ Date National Acupuncture Detoxification Association © NADA 2008 Training Manual Section X: Appendices 179 Appendix “G 2” Sample Program Forms: Client Consent to Treatment Treatment Description Acudetox is performed by placing thin, sterilized needles onto the surface of the ear. The treatment takes 45 minutes. Acudetox is usually done in a group setting. Treatments are provided by an Acudetox Specialist (ADS) or a professional acupuncture practitioner or supervised trainee. Possible Benefits of Treatment The use of acudetox for detoxification, recovery support and relapse prevention has been shown to be helpful in relieving acute symptoms of withdrawal from a variety of substances. Individuals often feel immediate relief and a decrease in tension and anxiety. Further treatment may reduce such withdrawal symptoms as profuse sweating, headache, body ache, stomach pain, runny nose, drug dreams and cravings. Participants may develop a greater sense of and connection with themselves. Voluntary I hereby voluntarily consent to be treated with acudetox. I understand that I may be treated with acupuncture needles and/or with the application of acupressure to the skin. I have not been guaranteed any specific outcomes concerning the uses and effects of acudetox. I understand that I am free to discontinue acudetox treatment at any time. However, I further understand that choosing to discontinue treatment may have an effect on my program status. Possible Side Effects/Healing Reactions I understand that acudetox may result in certain side effects, including local bruising, slight bleeding, fainting, temporary pain and discomfort, and temporary aggravation of symptoms existing prior to treatment. Conventional medicine therapy also may be indicated, either in response to an emergency or as deemed necessary at the discretion of a licensed health care practitioner. Medical Referral I understand that if there is a worsening of an ailment or condition, or if a new ailment or condition arises, I should consult a licensed physician. I also understand that if I am currently under a physician’s care, I should continue as long as my physician and I deem it necessary. This program does not recommend altering medications or other therapies without first consulting my personal physician or health care provider. Infectious Disease/Clean Needle Procedures I understand that there are infectious diseases which have the potential to be carried through the air, through physical contact, and through body fluids. I understand that ADSes/acupuncture practitioners follow universally prescribed precautions to guard against the spread of infection. In the case of blood-borne infections, such as hepatitis or HIV, I understand that the acudetox providers of this program follow strict precautions and use only sterilized, prepackaged, disposable needles. The acupuncture needles that are used for this treatment are single-use and applied according to nationally-based professional standards. I further understand that I am responsible for cleaning my ears with sterile alcohol pads or other skin cleansing agent prior to acudetox treatment and that the treatment center will provide these supplies. _____________________________ Client Name ____________________________ Client Signature __________ Date _____________________________ Witness Name (printed) ____________________________ Witness Signature __________ Date National Acupuncture Detoxification Association © NADA 2008 Training Manual Section X: Appendices 180 Appendix “G 3” Sample Program Forms: Notice of Privacy Practices THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED BY THE PROGRAM/TREATMENT PROVIDER AND HOW YOU MAY GET ACCESS TO THE INFORMATION. PLEASE REVIEW IT CAREFULLY. Use and Disclosure of Health Information The program/treatment provider may use your health information, information that constitutes protected health information as defined in the Privacy Rule of the Administrative Simplification provisions of the Health Insurance Portability and Accountability Act of 1996, for the purposes of providing treatment to you, obtaining payment for your care and conducting health care practices. Treatment – Your health information will be recorded and used to determine the course of treatment that should work best for you. The sharing of your health information may include other health care providers involved in your care. Payment – Your health care information may be used in order to receive payment for services. A bill may be sent to either you or a third-party payer with accompanying documentation that identifies you, your diagnosis, procedures performed and supplies used. Health Care Practices – Your health care information will be used as necessary in order to improve the quality and effectiveness of the care and services provided. For example, your case may be discussed with another health care provider for increased understanding of your unique situation. Appointment reminders – You may be contacted with appointment reminders. Please annotate program records with any limitations requested. Treatment Alternatives – You may be contacted with information about treatment alternatives and other health-related activities that may be of interest to you. Program Information Dissemination – You may be contacted to inform you of new services that are offered or of events that the program is hosting or attending. Communications with Family – In an urgent situation, a family member, significant other, or close personal friend; identified by you; may be given information relevant to your care. Research/Education – Your information may be disclosed to researchers or educators upon the assurance that protocols have been established to assure the privacy of your health information. Law Enforcement – Your health information will be disclosed when required under Federal, State or Local law. Other than so stated, the program agrees not to use or disclose your health information without your written authorization. Other than activity that has already occurred, you may revoke this authorization in writing at any time. National Acupuncture Detoxification Association © NADA 2008 Training Manual Section X: Appendices 181 National Acupuncture Detoxification Association © NADA 2008 Training Manual Section X: Appendices 182 Appendix “H” Selected Manuscripts on Addiction and Recovery “H 1” Brain Disease Model of Addictions Among the many difficulties faced in substance abuse treatment of any kind is the oft-held prejudice that the addict is just a morally weak individual who chooses not to control his or her compulsive behavior. Compelling research, performed in this country primarily by or under the auspices of the National Institute on Drug Abuse indicates that addictions is actually a brain disease in that many individuals have a genetic propensity to become addicted to one or several substances and/or behaviors. Other studies clearly show that even if an individual does not have the genetic predisposition for addictions, substance use and abuse can permanently alter brain chemistry and function. So if addiction is a disease, then why have treatment? The answer is simple, because it is a treatable disease just like diabetes and heart disease. It is fairly well known that both of these common maladies carry genetic components and through lifestyle changes (and when appropriate pharmacologic interventions) both are manageable. Interestingly enough, the percentage of insulin dependent diabetics and cardiac patients who choose not to maintain the recommended lifestyle modifications and therefore are often re-hospitalized for various morbidities is relatively equal to the percentage of addicted individuals who relapse after treatment. But is addiction really a disease even if research shows there may be a genetic predisposition or even brain chemistry changes? Allopathic medicine generally considers that to be a primary disease, a syndrome must exhibit these characteristics: • a genetic component, • it is chronic, • its course is progressive, and • if left untreated it can become fatal. In terms of addictions, as already mentioned, there is overwhelming evidence that shows there is a genetic component. Because of the long-term nature of this syndrome and the high tendency for relapse it is fairly obvious that, similar to diabetes and cardiac disease, addiction is chronic in its nature. In regards to the addicted individual, this chronic component often shows up as, “I used to get high to feel good, now getting high keeps me from feeling good.” Addiction also displays the progressive characteristic in that the individual begins to exhibit tolerance (manifesting as needing more of the substance to get the same high or that the same amount yields a diminished effect). In the life of the addict, this can be seen as initially the drug use interfered with his or her life, which then progresses to life interfering with the substance abuse. Lastly, just like diabetes and heart disease, there is little doubt that the individual who does not receive treatment and remains abstinent does indeed face the risk of death, either directly from an overdose or indirectly from HIV/AIDS, hepatitis C, drunk driving, liver or cardiac disease, cancer, etc. So given that addiction exhibits the four characteristics of a primary disease, it can now be concluded that it is indeed a disease, a disease that is treatable albeit one that requires lifestyle changes in order for it not to progress and become fatal. But from where does the brain part come in? Interestingly enough, it is through the neurobiological study of addiction that much of the brain mapping has taken place. While substances affect many parts of the brain, the primary area where addictions occur is the limbic system, the seat of basic emotions and learning. Located on the medial surface of the temporal National Acupuncture Detoxification Association © NADA 2008 Training Manual Section X: Appendices 183 lobe, this system is comprised of the olfactory lobe (the terminal end of the olfactory tract making smell the only special sense that does not pass through the thalamus), the amygdala (the nucleus that enables the H-P-A axis as well as the “fight or flight response”; also responsible for mood and conscious emotional response to an event) and the hippocampus (critical nucleus for storing longterm or declarative memory). There are four primary neurotransmitters1 found in the limbic system: dopamine, serotonin (5hydroxytryptamine or 5-HT), GABA (4-aminobutyrate) and endorphins (endogenous opiods that bind with receptor sites associated with blocking pain sensations and providing euphoric feelings). Each of these neurotransmitters is removed from the synapse after stimulating the post synaptic neuron by the pre-synaptic neuron via a process known as re-uptake in which the neurotransmitter is pumped back into the transmitting nerve cell. This serves two purposes: 1) assures the post-synaptic neuron is fired only once for each time the pre-synaptic neuron releases its neurotransmitter and, 2) maintains the supply of neurotransmitter so the neuron does not have to continually produce more. Using dopamine as an example in the following diagram, for a normal brain there is a basal level of dopamine being release and undergoing re-uptake. Upon perceiving an event as pleasant or pleasurable there is a smooth increase in dopamine release in the synapses. Once the stimulus ends, there is a relatively smooth return of the dopamine level to the basal level (recovery period). Located within the limbic system is the reward pathway (also called the pleasure pathway), the area of the brain that initiates the basic drives for survival of the species: food, water, nurturing and reproduction. The reward pathway begins at the ventral tegmental area (VTA), which releases dopamine that modulates the activity of the nucleus accumbens. The nucleus accumbens is where pleasure is perceived (recall that pleasure reinforces an action is good for the survival of the species). 1 Neurotransmitters are chemical messengers that are released by one nerve cell (neuron) into the synapse (area between two neurons) and received by the post-synaptic neuron. The post-synaptic neuron’s surface contains binding sites that are specific for different neurotransmitters. National Acupuncture Detoxification Association © NADA 2008 Training Manual Section X: Appendices 184 The reward pathway terminates at the prefrontal cortex, the most human part of the brain. This is where flexible thinking and mental control take place. The prefrontal cortex is where past integrates with the present and the future is anticipated. It is also where empathy exists. While receptors are located throughout the brain for substances generally considered drugs of abuse (heroin, cocaine, alcohol, tobacco, etc.), they are especially dense in the reward pathway (see figure next page). Numerous receptor sites for endorphins are also found in this area of the brain. In terms of the relative chances for success of remaining abstinent from a particular substance (and/or the amount of personal effort, growth and healing required), the further along the pathway its receptors are found, the more difficult it is to not relapse. Note in the following figure (next page) that the majority of receptor sites for cocaine and nicotine are located nearly at the prefrontal cortex area. Research indicates that this may be one of the reasons why remaining abstinent from these two drugs is so difficult. National Acupuncture Detoxification Association © NADA 2008 Training Manual Section X: Appendices 185 Regardless of whether someone has a genetic predisposition to addictions or not, the metabolites of the various potentially addictive drugs2 still have receptors in the reward pathway. So why do some people become addicted the first time they use a particular substance while others can use the same substance and not become hooked? The answer lies in the relative dopamine levels in the brains of the individuals with the genetic propensity towards addictions. Neurobiological research has shown that for the person with a predisposition for addictions, the relative basal synaptic dopamine levels are well below those seen in the brains for individuals without the propensity to become addicted (what was previously referred to herein as the normal brain). When pleasurable events occur for individuals with reduced basal dopamine levels, the normal gain in dopamine release is seen; only now the synaptic dopamine levels may only rise to the basal level of the normal brain. The implication of this is that at a very primitive subconscious level, these individuals are not receiving Behaviors such as gambling and other compulsive behaviors also stimulate the reward pathway and affect neurotransmitter levels in a similar way. The exact mechanisms are somewhat different and are not discussed here. 2 National Acupuncture Detoxification Association © NADA 2008 Training Manual Section X: Appendices 186 acknowledgment that their actions are good for the survival of the species. In other words, nothing they do tells the limbic system they are doing their part to keep humans alive on this planet. All substances that have the potential to become addictive work by increasing synaptic dopamine levels in the pleasure pathway. In essence this reinforces the behavior by having the person believe, again at the most primitive subconscious level, that using this substance is necessary for the survival of the species. For those individuals with a genetic predisposition for addictions (those with reduced basal synaptic dopamine levels), this may be the first time their brains have received this feedback and acknowledgment. Because these are the basic drives in all humans, having someone receive this feedback for the first time is a powerful reinforcement for that behavior. Seen in this light, the person displaying signs of addictions in not necessarily weak willed or morally defective, but rather, because of his or her genetic make-up, is driven to use by the same part of the brain that has kept life alive on this planet. What has just been described is the brain disease model of addictions and shows, at a neurobiological level, why remaining abstinent is so difficult for many people. And while not all individuals have the genetic predisposition component, there is a growing body of evidence that indicates there are permanent morphologic changes in the brains of all individuals who use and abuse certain substances (again, primarily in the reward pathway). Different substances affect dopamine levels in different ways. The opiods (morphine, heroin and pharmacologically derived analogs) fit into and stimulate do the same receptors as the endorphins and acts by stimulating increased dopamine release. Cocaine in its various forms acts by blocking the re-uptake pumps and thus the dopamine remains in the synapses much longer. This acts to continually re-stimulate the post-synaptic neurons. This, in turn, provides increased reinforcement of the activity. A long-term consequence of this action is that the receptor sites of the post-synaptic neurons eventually burn out and thus no stimulation can provide a sense of pleasure or reward leading to severe states of anhedonia. National Acupuncture Detoxification Association © NADA 2008 Training Manual Section X: Appendices 187 Appendix “H 2”: Steps Toward Change: Working with Ambivalence and Building Motivation for Change Ana Oliveira and Richard Elovich The role of counseling and group work: how do you work with an active or relapsing drug user to support self-directed behavior change? The crises of behavioral health issues, HIV and/or substance use in our communities demands that we maintain a learning and open-minded posture. Counseling effectiveness in any service setting is enhanced by using multiple approaches to match the multiple needs presented by individuals. By drawing on aspects of harm reduction, recovery readiness and treatment approaches to create steps toward change model, we have the opportunity to have a greater impact than if we were wedded to a single tool. By utilizing a steps toward change model, we can: Work with the individual wherever he/she may fall along the spectrum of drug use, abuse, dependency or recovery (i.e. highly involved with drugs, marginally involved, relapsing, in recovery, etc.); Avoid demanding that each individual be aware of drug involvement or be committed to transformation or abstinence; Work cooperatively with the individual to set his/her own priorities and timeline for action, rather than assume a hierarchy of issues to be dealt with; Operate without requiring individuals to take on any particular identity such as alcoholic, drug or sex addict; Develop effective alcohol and other drug related interventions integrated into the provision of other support, health and social services. Working with a stage paradigm of behavior change (Prochaska, DiClement) reaches a greater number of individuals. Rather than waiting for an individual to be motivated to change, a steps toward change model takes a proactive role in building motivation for change. It develops a relationship with the person, centered around building skills, awareness of inner change and connection to others engaged in similar process. This perspective works to develop motivation out of what the individual presents and out of an ongoing interaction between counselor and client, client and peers. Traditional harm reduction approaches have focused largely on externally based exchanges, i.e, the provision of materials and services. If an individual wants drug treatment or recovery they are often refereed elsewhere. The question becomes how does an individual get interested in change and how can that be supported by the harm reduction provider? A steps toward change approach, utilizing a stage paradigm and motivational counseling, operates within a context where services are provided and materials are exchanged, but it recognizes an inner process necessary to any change and fosters its development. For individuals, inner process can mean self-awareness, ability to make choices and set goals, assertiveness, recognition of feelings, identity and self-acceptance, etc. Working with one’s internal reality is the foundation for any self-directed change or transformation. National Acupuncture Detoxification Association © NADA 2008 Training Manual Section X: Appendices 188 Group work. The individual process of change or transformation takes place within a social context. Experiential learning is accomplished among peers. Group work is critical because it provides: A mirroring process where individuals can observe or experience similarities or contrasts in thoughts, feeling actions; An opportunity to experience oneself in the presence of others, breaking the isolation, fear and shame; An opportunity to witness and model a peer transformational process, i.e. efforts, attitude and behavior changes, social relationships; Support for the development of alternative social networks that reinforce process of transformation; Clear parameters or limits for interaction. Utilizing a steps toward change approach with a strong emphasis on peer support and mutual help sustains not only a particular behavior change but promotes the engagement and ongoing involvement in the process of self-directed change and growth. Regardless of any specific behavior change, it helps many individuals alter the nature of their relationship to the group, supporting them as they move from initially being fearful, threatened or anxious to a point where they can carry the group within them as a guide and companion. Individuals often find that taking the risk to share feelings, experiences and thoughts strengthens their connection and commitment to the group. The group provides a “container” for their individual process of growth. Peer educators. Participation in the group automatically ascribes its members with the role of peer educators. As the process of change unfolds individuals become aware of their ability to have an impact on their peers. In turn, this builds self-efficacy and self-esteem, which are essential for the maintenance and continuation of the change process. Sharing what they have experienced and what they’ve learned becomes the mode by which they remain engaged, perceive their own growth, and transcend their own lack of self-esteem, isolation and neediness. It gives them a role by which they can have an impact on others. The steps toward change model, drawing from harm reduction, recovery readiness and treatmentbased philosophies, is an expansive or organic process which encourages “clients” to become peer counselor and educators. Unlike approaches which foster loyalty to the program or to the modality, this process is grounded in self-directed and autonomous choices. National Acupuncture Detoxification Association © NADA 2008 Appendix “H 3” Information on Alcoholics Anonymous Training Manual Section X: Appendices 189 For Anyone New Coming to A.A. For Anyone Referring People to A.A. This information is both for people who may have a drinking problem and for those in contact with people who have, or are suspected of having, a problem. Most of the information is available in more detail in literature published by A.A. World Services, Inc. This sheet tells what to expect from Alcoholics Anonymous. It describes what A.A. is, what A.A. does, and what A.A. does not do. What Is A.A.? Alcoholics Anonymous is an international fellowship of men and women who have had a drinking problem. It is nonprofessional, self-supporting, multiracial, apolitical, and available almost everywhere. There are no age or education requirements. Membership is open to anyone who wants to do something about his or her drinking problem. Singleness of Purpose and Problems Other Than Alcohol Some professionals refer to alcoholism and drug addiction as “substance abuse” or “chemical dependency.” Nonalcoholics are, therefore, sometimes introduced to A.A. and encouraged to attend A.A. meetings. Anyone may attend open A.A. meetings, but only those with a drinking problem may attend closed meetings. A renowned psychiatrist, who served as a nonalcoholic trustee of the A.A. General Service Board, made the following statement: “Singleness of purpose is essential to the effective treatment of alcoholism. The reason for such exaggerated focus is to overcome denial. The denial associated with alcoholism is cunning, baffling, and powerful and affects the patient, helper, and the community. Unless alcoholism is kept relentlessly in the foreground, other issues will usurp everybody’s attention.” What Does A.A. Do? 1. A.A. members share their experience with anyone seeking help with a drinking problem; they give person-toperson service or "sponsorship" to the alcoholic coming to A.A. from any source. 2. The A.A. program, set forth in our Twelve Steps, offers the alcoholic a way to develop a satisfying life without alcohol. 3. This program is discussed at A.A. group meetings. a. Open speaker meetings — open to alcoholics and nonalcoholics. (Attendance at an open A.A. meeting is the best way to learn what A.A. is, what it does, and what it does not do.) At speaker meetings, A.A. members “tell their stories.” They describe their experiences with alcohol, how they came to A.A., and how their lives have changed as a result of Alcoholics Anonymous. b. Open discussion meetings — one member speaks briefly about his or her drinking experience, and then leads a discussion on A.A. recovery or any drinking-related problem anyone brings up. (Closed meetings are for A.A.s or anyone who may have a drinking problem.) c. Closed discussion meetings — conducted just as open discussions are, but for alcoholics or prospective A.A.s only. d. Step meetings (usually closed) — discussion of one of the Twelve Steps. National Acupuncture Detoxification Association © NADA 2008 Training Manual Section X: Appendices 190 e. A.A. members also take meetings into correctional and treatment facilities. f. A.A. members may be asked to conduct the informational meetings about A.A. as a part of A.S.A.P. (Alcohol Safety Action Project) and D.W.I. (Driving While Intoxicated) programs. These meetings about A.A. are not regular A.A. group meetings. What A.A. Does Not Do A.A. does not: 1. Furnish initial motivation for alcoholics to recover 2. Solicit members 3. Engage in or sponsor research 4. Keep attendance records or case histories 5. Join “councils” of social agencies 6. Follow up or try to control its members 7. Make medical or psychological diagnoses or prognoses 8. Provide drying-out or nursing services, hospitalization, drugs, or any medical or psychiatric treatment 9. Offer religious services or host/sponsor retreats. 10. Engage in education about alcohol 11. Provide housing, food, clothing, jobs, money, or any other welfare or social services 12. Provide domestic or vocational counseling 13. Accept any money for its services, or any contributions from non-A.A. sources 14. Provide letters of reference to parole boards, lawyers, court officials, social agencies, employers, etc. National Acupuncture Detoxification Association © NADA 2008 Training Manual Section X: Appendices 191 Members From Court Programs and Treatment Facilities In recent years, A.A. groups have welcomed many new members from court programs and treatment facilities. Some have come to A.A. voluntarily; others, under a degree of pressure. In our pamphlet “How A.A. Members Cooperate,” the following appears: We cannot discriminate against any prospective A.A. member, even if he or she comes to us under pressure from a court, an employer, or any other agency. Although the strength of our program lies in the voluntary nature of membership in A.A., many of us first attended meetings because we were forced to, either by someone else or by inner discomfort. But continual exposure to A.A. educated us to the true nature of the illness.... Who made the referral to A.A. is not what A.A. is interested in. It is the problem drinker who is our concern.... We cannot predict who will recover, nor have we the authority to decide how recovery should be sought by any other alcoholic. Proof of Attendance at Meetings Sometimes, courts ask for proof of attendance at A.A. meetings. Some groups, with the consent of the prospective member, have the A.A. group secretary sign or initial a slip that has been furnished by the court together with a self-addressed court envelope. The referred person supplies identification and mails the slip back to the court as proof of attendance. Other groups cooperate in different ways. There is no set procedure. The nature and extent of any group’s involvement in this process is entirely up to the individual group. This proof of attendance at meetings is not part of A.A.’s procedure. Each group is autonomous and has the right to choose whether or not to sign court slips. In some areas the attendees report on themselves, at the request of the referring agency, and thus alleviate breaking A.A. members’ anonymity. Literature A.A. Conference-approved literature is available in French and Spanish. For additional copies of this paper, or for a literature catalog please write or call the General Service Office. The A.A. Grapevine, a monthly international journal — also known as “our meeting in print” — features many interesting stories about recovery from alcoholism written primarily by members of A.A. It is a useful introduction and ongoing link to A.A.’s diverse fellowship and wealth of recovery experience. The Spanishlanguage magazine La Viña, is published bimonthly. For Grapevine information or to order a subscription to either the AA Grapevine or La Viña: (212) 870-3404; fax (212) 870-3301; Web site: www.aagrapevine.org. Conclusion The primary purpose of A.A. is to carry its message of recovery to the alcoholic seeking help. Almost every alcoholism treatment tries to help the alcoholic maintain sobriety. Regardless of the road we follow, we all head for the same destination, recovery of the alcoholic person. Together, we can do what none of us could accomplish alone. We can serve as a source of personal experience and be an ongoing support system for recovering alcoholics. A.A. World Services, Inc., Box 459, Grand Central Station, New York, NY 10163 Tel. (212) 870-3400. www.aa.org National Acupuncture Detoxification Association © NADA 2008 Training Manual Section X: Appendices 192 “H 4” Acudetox and the Serenity Prayer Shellie Goldstein LAc Effects of Acupuncture Acupuncture helps you to relax, focus, and get in touch with yourself and your emotions. In an addictions / behavioral health treatment setting acudetox treatment helps you become more attentive and participatory in groups. It is an effective drug-free group alternative. NADA Protocol and the Serenity Prayer The serenity prayer is a hallmark of substance abuse treatment in this country. The NADA 5 point ear protocol complements the meaning and significance of the serenity prayer. The NADA 5 Point Ear Acupuncture Protocol The NADA 5 Point Ear Acupuncture Protocol is used to decrease withdrawal symptoms, shorten the length of the withdrawal process, and prevent anxiety which may lead to potential relapse. In addition, acupuncture improves the quality of sleep, stabilizes emotions, and helps to reestablish internal balance. The NADA five ear points are as follows: Sympathetic Shen Men Kidney Liver Lung Sympathetic (physical relaxation) The sympathetic point when stimulated with acupuncture treatment, balances our sympathetic system. It helps to relax the sympathetic nervous system, our fight or flight response, and allow its counterpart, the parasympathetic system, (our ability to relax), to predominate. In essence by treating the sympathetic point we are helping the entire body to physically relax. Shen Men (emotional/spiritual awareness) Shen Men, means spirit gate, and when stimulated through acudetox, it opens the door to our inner awareness and higher power. It helps us to relax emotionally and evolve spiritually. The Kidneys (the big picture) The Kidney system in Chinese Medicine is the root of our energy. It gathers and stores our jing, pre and post natal qi. Its health reflects our growth and development from birth through death. When our kidney energy is strong, we grow and mature appropriately, and age with youthful vitality. As the foundation of our being, the Kidneys also dominate the way that our mind and thoughts develop. When treating the Kidney energy with acudetox we can open the door to the wisdom of our internal awareness. There comes a time (or many times) when age and self awareness collide. Often referred to as the ‘mid-life crisis’ it is that moment when time and destiny meet. Like an illuminated light-bulb, it is a moment of reflection, an opportunity to review ones past achievements, and to re-evaluate future visions. It is the realization that unfulfilled dreams have yet to come as the endless sense of time that we once took for granted is dwindling. National Acupuncture Detoxification Association © NADA 2008 Training Manual Section X: Appendices 193 For clients in chemical dependency treatment it is that momentary flash of “Oh my God! I am ___ years old, I have been _____________ (using drugs, been in and out of prison,…) and if I continue down this path, my life will be over before I have the chance to live it.” For some, this realization is life changing. For others it is a fleeting moment. Ear acupuncture on the kidney point helps to hold the door open, keep the light bulb illuminated, and help you to deal with the fear of change that comes when realizing, reevaluating, and potentially changing your life. The Liver (the cycles of life) The Liver system in Oriental medicine governs the way that qi flows throughout the body. As the army general, its job is to maintain a smooth flow of internal qi and blood. We know that the body, mind, and spirit function optimally when in a state of balance. Life and our life’s activities can easily throw us out of harmony. The cycles of life and the emotion of anger are both related to the Liver. When the Liver system is imbalanced, it creates chaos within and without. Anger flares and as a result inappropriate behavior occurs. In a drug related setting, it is often this rash and volatile behavior that gets one in trouble both with oneself and the law. Treating the liver system helps you to stay calm and creates internal quiescence such that one can learn to respond to life rather than react to it. When this occurs, our behavior and decisions are more appropriate. When faced with the perception of danger (i.e.: someone verbally or physically assaulting you) the natural response within the addicted / behaviorally challenged population is to fight back (verbally or physically). Whether right or wrong, the repercussions may span from injury (internal or external) to death. In addition, it is generally the self-justification for relapse. To change ones behavior (i.e. choose to walk away vs. fight back) requires the courage to know that in that moment you are safe, secure, and strong enough to walk away. Acupuncture treatment on the Liver point empowers you to choose rather than react. The Lungs (the moment) The Lung system governs the moment to moment taking in and letting go of oxygen, life, and our feelings, particularly that of sadness. Most people in CD treatment have suffered personal loss either due to drugs, alcohol, and/or lifestyle. This loss can also be related to the loss of ones’ own youth, childhood, adolescence, and even adulthood due to the use of drugs and alcohol. The act of breathing helps to put us in touch with our feelings. For this reason, it is often difficult for addicts and behavioral health participants who are not used to dealing with their emotions, to breathe deeply. The Lung point in ear acupuncture helps this population to gently accept the moment, accept their feelings, and to deal with the sadness and grief for the losses in their lives. Acudetox helps your body to heal itself. The beauty here is that it does not push you, but rather it guides you in the direction of healing. (Empty Fire…) The Serenity Prayer God, (Shen Men) grant me the serenity (Shen Men & Sympathetic) to accept the things that I can not change (Lungs) the courage to change the things I can (Liver) and the wisdom to know the difference (Kidney) National Acupuncture Detoxification Association © NADA 2008 Training Manual Section X: Appendices 194 Appendix “H 5” National Acupuncture Detoxification Association © NADA 2008 Training Manual Section X: Appendices 195 National Acupuncture Detoxification Association © NADA 2008 Training Manual Section X: Appendices 196 Jellinek Chart of Alcoholism and Recovery “H 6” National Acupuncture Detoxification Association © NADA 2008 Training Manual Section X: Appendices 197 Appendix “H 6”:Symptoms and Phases of Alcoholism in Women (Jellinek Chart for Women) Have you ever experienced: Prodromal Phase 1. Increased tolerance (need to drink more to get the same effect? 2. Unwillingness to discuss drinking? 3. Feelings that women who drink excessively are worse than men? 4. Personality changes when drinking? 5. Drinking more just before your menstrual period? 6. Feeling more intelligent and capable when drinking? 7. Being “supersensitive”? Yes Early Stage 8. Periods of abstinence (times when you’ve tried to stop drinking)? 9. Disapproval from others about your drinking? 10. Rationalizing (making excuses for) drinking? 11. Temporary losses of memory (blackouts, times you couldn’t remember what you did) when drinking? 12. Unexplained bruises or injuries? 13. Drinking before facing a new situation? Middle Stage 14. Neglecting eating? 15. Protecting your supply (hiding a “stash” of alcohol)? 16. Self-pity (feeling sorry for yourself)? 17. Feeling resentful toward others? 18. Being permissive or lax with your children because of guilty feelings about drinking? 19. Drinking to feel happier but finding yourself feeling more depressed? 20. Being told by others that you “couldn’t be an alcoholic”? 21. “Predrinking” – drinking before a drinking occasion; or “postdrinking” – continuing to drink after a drinking occasion? 22. Feeling guilty about drinking? 23. Drinking more or less continuously for a period of at least 18 hours? Chronic Phase 24. Starting the day with a drink? 25. Tremors (shaky hands)? 26. Decreased tolerance (feeling and acting drunk after just one drink)? 27. Sneaking drinks? 28. Gulping drinks? 29. Persistent remorse? 30. Devaluing personal relationships? 31. Carrying liquor in your purse? Source: Adapted from James, J. E. (1975). Symptoms of alcoholism in women: A preliminary survey of AA members. Journal of Studies on Alcohol 36(11):1564-1569, as cited in National Institution on Alcohol Abuse and Alcoholism. (1995). Twelve-step facilitation therapy manual. (Volume 1: Project MATCH Series). Rockville, MD: Author. Reprinted with permission from Journal of Studies on Alcohol, vol. 36, pp. 1564-1569, 1975. Copyright by Journal of Studies on Alcohol Inc., Rutgers Center of Alcohol Studies, Piscataway, NJ 08854. National Acupuncture Detoxification Association © NADA 2008 Training Manual Section X: Appendices 198 Appendix “H 6”:Symptoms and Phases of Alcoholism in Men (Jellinek Chart for Men) Have you ever experienced: Prodromal Phase 1. Increased tolerance (need to drink more to get the same effect)? 2. Temporary loss of memory (blackouts, times you couldn’t remember what you did)? 3. Sneaking a drink when no one was looking? 4. Preoccupation with drinking (thinking about drinking while working, etc.)? 5. Hurried drinking (“chasing a high”)? 6. Avoiding talking about your drinking because it made you uncomfortable? 7. Loss of memory (can’t remember things you said, what you were supposed to do)? Yes Crucial (basic) Phase 8. Loss of control (unable to predict how much you’ll drink)? 9. Justifying (making excuses for drinking)? 10. Disapproval from others about your drinking? 11. Being extravagant with money? 12. Aggression (verbal or physical)? 13. Remorse (or guilt or depression about drinking)? 14. Periods of abstinence (times when you tried to stop drinking)? 15. Changes in your pattern of use (switching types or brands of alcohol)? 16. Losing friends (or having fights with them) on account of your drinking? 17. Losing a job or getting into trouble at work on account of drinking? 18. Giving up old hobbies or activities in order to spend time drinking? 19. Having to get treatment of some form for your drinking? 20. Feeling resentful a lot toward others? 21. Escape (moving or changing friends in an effort to get a “fresh start”)? 22. Protecting your supply (hiding a stash of alcohol)? 23. Drinking in the morning (or before work)? Chronic Phase 24. Drinking more or less continuously for at least 18 hours (a “binge”)? 25. Doing things that violate your own ethical or moral standards? 26. Inappropriate (or confused) thinking, such as hearing voices or not knowing where you are? 27. Decreased tolerance (feeling and acting drunk after just one drink)? 28. Vague fears or anxiety? 29. Tremors (shaky hands)? 30. Feeling hopeless or suicidal? Source: Adapted from Jellinek, E. M. (1964). A chart of alcohol addiction and recovery. Journal of the Iowa Medical Society. March, as cited in National Institution on Alcohol Abuse and Alcoholism. (1995). Twelve-step facilitation therapy manual . (Volume 1: Project MATCH Series). Rockville, MD: Author. Chart is reprinted with permission from the Journal of the Iowa Medical Society. National Acupuncture Detoxification Association © NADA 2008 Training Manual Section X: Appendices 199 Appendix “H 7”: Client Self-Questionnaire Your Name: _____________________________________ Social Security No: ________________ Today’s Date: __________________ Counselor Reviewing Answers: _______________________ CAGE Questions • • • • Have you felt the need to Cut down on your drinking/drugging? Are you Annoyed by people complaining about your drinking/drugging? Do you feel Guilty about your Drinking/Drugging? Do you ever need an Eye-opener in the morning to relieve shakes? Scoring: 2 or more yes answers suggest client has challenges with drinking/drugging Y Y Y Y N N N N DSM-IV Based Criteria Questions for Determining Substance Dependence • • • • • • • Do you find yourself having to use more of a substance to get the desired high? Have you experienced physical or psychological withdrawal symptoms when you stopped using a substance? Have you taken a substance in larger amounts or for a longer time than intended? Within the past 12 months, have you wanted to cut back but were unsuccessful? Have you spent a great deal of time seeking, using and recovering from the effects of the substance? Have important social, recreational or work related activities been given up or reduced as a result of your substance use? Have you continued taking a substance despite knowing repeated physical or psychological problems have been caused or made worse by its use? Scoring: 3 or more yes answers indicate a diagnosis Substance Dependence Y Y Y Y Y Y Y N N N N N N N DSM-IV Based Criteria Questions for Determining Substance Abuse • • • • Within the past 12 months, has your substance use resulted in your inability to fulfill important obligations at work, school or home? Have you repeatedly used substance(s) in situations that were physically hazardous? Within the past 12 months have your experienced substance-related legal problems? Have you continued using despite continuing social or interpersonal problems caused or made worse by the effects of the substance? Scoring: one or more yes answers indicate a diagnostic impression of Substance Abuse Y Y Y Y N N N N Client’s Signature: __________________________________________ Date: ______________ Counselor’s Signature: Date: _______________ National Acupuncture Detoxification Association © NADA 2008 Training Manual Section X: Appendices 200 Appendix “I” Supplies, Vendors and Publications “I 1” General Supplies List The following are considered the minimum supplies necessary to begin a NADA-style acudetox program. Quantities will be dependent upon the number of clients treated, number of days per week treatment occurs, etc. Supplies cabinet/cart (either needs to be locking or stored in a secure area) Comfortable chairs, preferably with head/arm support Lined trash can Hazardous waste containers (and state approved disposal service) or equivalent Sharps container(s) for needle disposal – this can be done several ways: • pint size sharps containers that can be carried to the client and placed under his or her ear as the needles are removed (see vendor list). • one large stationary container (use puncture-proof cups such as urine specimen containers that the practitioners carry to the clients to collect the needles and then dump the needles into the large container. Containers should be sanitized between sessions.) • 2 oz. – 3 oz. plastic cups. Clients may receive individual plastic cups to “catch” stray needles that fall out during treatment, and at a time of needle removal. Inexpensive “bathroom” cups or the “sample” cups commonly used at grocery stores are ideal for this purpose. The base of the cup exactly fits the ½ inch sized Anti-microbial gel, hand wipes, foam or solution if there is not a hand-wash sink in the room. Non-latex gloves in small, medium, large for needle removal Alcohol pads or equivalent Cotton balls (bulk/non-sterile) or cotton swabs Acupuncture ear needles. ½ inch (or ¼ inch), 32 – 38 gauge, sterile, disposable, stainless steel Sleepmix tea or equivalent Ear seeds/beads Documentation and consent forms, client information handouts Optional: Plastic ear models (good to have around to show clients) Relaxation music (no vocals or percussion rhythms) and player National Acupuncture Detoxification Association © NADA 2008 Training Manual Section X: Appendices 201 “I 2” Vendors While the National Acupuncture Detoxification Association does not endorse any particular vendors, the following have continually provided support to NADA’s mission and donated supplies to NADA benefit trainings. The products below are used by many providers but are by no means the only possible or recommended supplies. Needles, seeds/beads, sharps containers (also tweezers, ear models): Needles: ½ or ¼ inch, 32-38 gauge. Helio Medical Supply 606 Charcot Avenue San Jose, CA 95131 800-yinyang (946-9264) www.heliomed.com • Needles: ¼ - ½ inch, 32 – 38 gauge, for example: o Viva Cluster Pack, 36 g (5 needles/pack): VT5-3605 o Vinco Cluster Pack 38g (5 needles/pack): NT5-3805 (100 packs/box) o Vinco Cluster Pack 36g (5 needles/pack): NT5-3605 (100 packs/box) • Ear Seeds: Helio Ear Seeds (100/box): ES-01/Ear Beads: gold ES-02 • One Pint Needle Disposal Container: GS-215 Lhasa OMS 539 Accord Station Accord, MA 02018 800-722-8775 www.lhasaOMS.com ACP Medical Supplies, Inc. 118 Baywood Avenue Longwood, FL 32750 877-248-4539 www.acpmedical.com • Needles: ¼ - ½ inch, 32 – 38 gauge, for example: o Carbo Cluster Pack 36g (5 needles/pack): CT5-3605 (100 packs/box) • Ear Seeds: Carbo Ear Seeds (100/box): ES-01/Ear Beads: gold or silver Health Point Products, Inc. 1804 Plaza Avenue, Suite 21 New Hyde Park, NY 11040 888-684-5575 - Fax 516-328-6926 www.1hpi.com • Chinese auricular acupoints plasters (100/pack): Magnet pellet 100 Insurance American Acupuncture Council National Acupuncture Detoxification Association © NADA 2008 185 East First Street Suite 1160 Santa Ana, CA 92705 800-838-0383 Van Wagner & Associates PO Box 5710 Bay Shore, NY 11706 800-735-1588 Herbal Sleepmix Tea Nutracontrol Box 1199 Old Chelsea Station New York, NY 10011 212-929-3780 Training Manual Section X: Appendices 202 National Acupuncture Detoxification Association © NADA 2008 Publications Literature, reprints, general information NADA Literature Clearinghouse PO Box 1927 Vancouver, WA98668 888-765-NADA (6232) www.acudetox.com Current NADA Clearinghouse offerings: The Writings of Michael O. Smith, MD, D, Ac • Acupuncture for Addiction Treatment - $16.50 Training Manual Section X: Appendices 203 The basic, persuasive case. A proven tool for introducing the subject to new audiences, especially officials, funders and other decision-makers who can help or hinder your projects. This concise review of research and practice in booklet form is printed on heavy coated paper with a four-color die-cut cover. • Acupuncture for Treatment of Cocaine Addiction - $16.50 Aiming at an audience of addiction professionals looking for answers, Dr. Smith goes into detail on how acupuncture detoxification principles evolved in the real world of the cocaine epidemic. On heavy coated paper with a four-color die-cut cover, this booklet is a basic item for your professional library. • The Nature of Qi - $16.50 Why research often misses the healing effect. Analyzes why current Western research concepts give faulty guidance to the scientific study of Qi-flow therapies, while introducing clinicians to the patient's own healing powers. Printed in same high impact format as TRM 1 and TRM 2 Get All Three Dr. Michael O. Smith Essays - $39.99 The Guide to Acu Detox Research - $29.99 “What is the research base for acu detox?” Answer this perennial question with the new edition of The Guide, summarizing relevant research 2003-2006. Includes complete citations and bibliography. Tools for NADA Work • Role of Public Policy in Use of ADS - $14.50 Your guide to legislative and regulatory action. • Includes color chart of statutes and regulations in ADS-friendly states and provinces. Magnetic Beads and ADHD - $7.50 Summary of reports by Michael O. Smith MD, D Ac. • Promising results are seen in pilot applications with a variety of child psychiatric diagnoses. Points to Change VHS - $12.00 DVD - $14.00 National Acupuncture Detoxification Association © NADA 2008 • Training Manual Section X: Appendices 204 An excellent 27-minute video giving an overview of acu detox. Excellent as a training and outreach tool or for patient education. NADA Points Ear Chart - $9.75 A large 11”x 14” wall or easel chart useful for training ADS and educating patients. Printed on heavy stock and laminated. The NADA Papers • Acupuncture Detoxification Basics - $31.99 A compact summary of the core concepts. Acupuncture Treatment for Alcoholism -- A comprehensive statement of the NADA principles of treatment Acupuncture Treatment of Chemical Dependency and Violence -- Practical clinical observations Auricular Acupuncture Treatment for Chemical Dependency -- Review of pioneer research literature Acupuncture: New Perspectives in Chemical Dependency Treatment – How integration began. Research and Outcome Studies - $31.99 Summarizes key research findings and gives tools for planning research of your own. Controlled Trial of Acupuncture for Severe Recidivist Alcoholism -- Landmark article from The Lancet Lincoln Hospital Acupuncture Drug Abuse Pgm.-- Testimony to US House of Rep. Testimony to Office of Alternative Medicine of NIH re: Efficacy of Acupuncture in Varied Sites . WHO'S Study -- Outcome evaluation of acupuncture impact on patients of a residential treatment program in Australia Portland Links Acupuncture with Housing for Good Outcomes: Incl Lit Review thru 1999. Value of Acup. Detox. Progs. in a Sub. Abuse Trtmt. System -- The "Boston Study" Launching and Running a Program - $31.99 What you need to get started (or decide if you want to). Ethics of Acupuncture Detoxification Specialists -- Foundation document for ADS practitioners The Kent-Sussex Program: A Case for ADSes -- A concrete case study. The Integration of Acupuncture into Existing Chemical Dependency Treatment Programs -- Covers varied sites Long-Term Program Sustainability -- Alex Brumbaugh on keeping the acupuncture detoxification component fresh Creating an Acupuncture Treatment Program for Addiction -- A step by step approach to getting it done So You Want to Start an Acupuncture Detoxification Program? -- The famous recounting of hard-earned experience NADA Opens Doors for Acupuncturists. -- An acupuncturist writes on value of non-LAc ADS What is Acupuncture? -- Lincoln Hospital Patient Education Handout Acupuncture Helps Programs More Than Patients -- Comments on the pathology of the system Informed Consent for Acupuncture--(English and Spanish) Clinical Fundamentals - $31.99 Acupuncture detoxification pioneers share the knowledge and skills needed to facilitate recovery. Acupuncture and Natural Healing -- Reprint from American Journal of Acupuncture Chinese Theory of Acupuncture Detoxification -- Brief statement of underpinnings of auricular therapy Acupuncture Detoxification for Homeless Substance Abusers -- Helping this special population Raising Healthy Babies in a World of Drugs -- Lincoln Hospital's response to maternal crack use American Hospital Assoc. Case Study No. 10 -- Lincoln Hospital Perinatal Program Relation of Maternal Involvement in Drug Treatment and Prenatal Care to Infant Birth Weight -- Results at Lincoln Acupuncture as a Treatment for Drug Dependent Mothers -- Testimony to the New York City Council Violence, Trauma and Posttraumatic Stress Disorder Among Women Drug Users -- Shows high frequency of PTSD The Healing Crisis Does Chinese Energy Flow Theory Conflict with Western Medical Theory? Abuse Patterns--According to Chinese Diagnosis Acupuncture Treatment for Cigarette Smoking -- The role of acupuncture in this clinical challenge • • • National Acupuncture Detoxification Association © NADA 2008 Training Manual Section X: Appendices 205 • Criminal Justice and Drug Courts - $18.50 Acupuncture detoxification helps justice sanctions combine with treatment to result in court- and jail-based recovery. Use of Acupuncture in the Criminal Justice System -- Basic statement of the proper role of the treatment provider The Advantages of the Drug Court Treatment System -- How it can obtain better results than orthodox treatment Acupuncture: An Important Tool for Treating Drug Dependent Offenders -- Article from probation/parole viewpoint Drug court outcome: US Govt. study on acupuncture-based program. Mental Disorders - $18.50 Explores new possibilities for acupuncture treatment of depression, psychosis, ADHD and the co-occuring disorder patient. Mental Health Treatment Outcome Report from Biscailuz Jail, Los Angeles -- Documents dual diagnosis impact New Applications for Acupuncture Detoxification: A round up of data on its use for PTSD, violence, ADD, impulse control Psychiatric Functions of Acupuncture -- Deals with anxiety, psychotropics, schizophrenia, depression, stress, hysteria Acupuncture as Treatment for the Borderline Personality Disorder Ear Acupuncture for Persons with Serious Mental Illness and Substance Use Disorder -- Outcomes of Texas program. • Books on Acudetox in Recovery Brumbaugh, A (1993). Transformation and Recovery: A Guide for the Design and Development of Acupuncture-Based Chemical Dependency Treatment Programs. Still Point Press, 133 East De La Guerrra Street, Ste 362, Santa Barbara, CA, 93101. Out of Print but limited copies available via: www.redwingbooks.com Websites www.drugabuse.gov www.jointogether.org www.samhsa.gov National Acupuncture Detoxification Association © NADA 2008 Appendix “I” Acudetox References Training Manual Section X: References 205 Ackerman, R.W. (1995). Acupuncture as treatment for substance abuse and its application during pregnancy. Vancouver, WA: NADA Literature Clearinghouse. Ackerman RW (1995). Auricular acupuncture treatment for chemical dependency: a review of the literature. Vancouver, WA: NADA Literature Clearinghouse. Ackerman RW (1993, rev. 1998). Elements of U.S. Drug Policy. Acupuncture (1997). NIH Consensus Statement, Nov. 3-5; 15(5): 1-34. Avants SK, Margolin A, Holford TR, Kosten TR (2000). A randomized controlled trial of auricular acupuncture for cocaine dependence. Archives of Internal Medicine, 160(5): 2305-2312. Baum AS, Burnes DW (1993). A Nation in Denial: The Truth About Homelessness. San Francisco, Boulder, Oxford: Westview Press. Berman AH, Lundberg U, Krook AL, Gyllenhammar C (2004). Treating drug using prison inmates with auricular acupuncture: A randomized controlled trial. Journal of Substance Abuse Treatment, 26: 95 – 102. Bier ID, Wilson J, Studt, P, Shakleton, M (2002). Auricular acupuncture, education and smoking cessation: A randomized, sham controlled trial. American Journal of Public Health, 92, 1642 – 1647. Boucher TA, Kiesuk TJ, Trachtenberg AI (2003). Complementary and alternative therapies. In: Graham AW, Schultz TK, Mayo-Smith MF, Ries RK and Wilford BB, eds. Principles of Addiction Medicine. 3d Ed. Chevy Chase, MD: American Society of Addiction Medicine. pp. 509 – 532. Brewington V, Smith M, Lipton D (1994). Acupuncture as a detoxification treatment: An analysis of controlled research. Journal of Substance Abuse Treatment, 11(4): 289-307. Brumbaugh A (1993). Transformation and Recover: A Guide for the Design and Development of Acupuncture-Based Chemical Dependency Treatment Programs. Santa Barbara, CA: Still Point Press. Bullock ML, Culliton PC, Olander RT (1989, June 24). Controlled trial of acupuncture for severe recidivistic alcoholism. The Lancet,1435-1439. Bullock ML, Ulmen AJ, Culliton PD, and Olander RT (1987 May-June). Acupuncture treatment of alcohol recidivism: A pilot study. Alcoholism: Clinical and Experimental Research, 11(3): 292-295. National Acupuncture Detoxification Association © NADA 2008 Training Manual Section X: References 206 Bullock ML, Kiresuk TJ, et al (2002). A large randomized placebo controlled study of auricular acupuncture for alcohol dependence. Journal of Substance Abuse Treatment, 22: 71-77. Center for Substance Abuse Treatment (2006). Detoxification and Substance Abuse Treatment. Treatment Improvement Protocol (TIP) Series 45. DHHS Publication No. (SMA) 064131. Clavel-Chapelon F, Paoletti C, Banhamou S (1997). Smoking cessation rate 4 years after treatment by nicotine gum and acupuncture. Preventative Medicine, 26(1): 25-28. Finigan M (1998). An outcome program evaluation of the Multnomah County S.T.O.P. Drug Diversion Program. Prepared for Multnomah County Department of Community Corrections. Flanagan LW (1995). Meeting the special needs of females in custody: Maryland’s unique approach. Federal Probation, 59(2): 49 – 53. Guidepoints: News from NADA. Professional newsletter, 7402 NE 58th St., Vancouver, WA 98662. Hancock E (1999). Bare bones acupuncture, big time recovery. Meridians. 6(2): 17-24. He D, Berg JE, Høstmark AT (1997). Effects of acupuncture on smoking cessation or reduction for motivated smokers. Preventative Medicine, 26(2): 208-214. He D, Medbø JI, Høstmark AT (2001). Effect of acupuncture on Smoking Cessation or Reduction: An 8-month and 5-year follow-up study. Preventative Medicine, 33: 364-372. Killeen TK, Haight B, et al (2002). The effects of auricular acupuncture on psychophysiological measures of cocaine craving. Issues in Mental Health Nursing, 23: 445 – 459. Konefal J, Duncan R, Clemence C (1995). Comparison of three levels of auricular acupuncture in an outpatient substance abuse treatment program. Alternative Medicine Journal, 2(5)1. Kutchins S (1991). The treatment of smoking and nicotine addiction with acupuncture. In Cocores, I. A. (Ed.) The Clinical Management of Nicotine Dependence. New York: Springer Verlag. Li M, Chen K, Mo Z (2002). Use of qigong therapy in the detoxification of heroin addicts. Alternative Therapies, 8(1): 50-58. Lipton DS, Brewington V, Smith MO (1994). Acupuncture for crack-cocaine detoxification: Experimental evaluation of efficacy. Journal of Substance Abuse Treatment, 11(3): 205215. National Acupuncture Detoxification Association © NADA 2008 Training Manual Section X: References 207 Margolin A, Avants SK, Chang P, Kosten TR (1993). Acupuncture for the treatment of cocaine dependence in methadone-maintained patients. The American Journal on Addictions, 2(3): 194-201. Margolin A, Chang P, Avants SK, Kosten TR (1993). Effects of sham and real auricular needling: Implications for trials of acupuncture for cocaine addiction. American Journal of Chinese Medicine, 21(2), 103 – 111. Margolin A, Avants SK, Chang P, Birch S, Kosten TR (1995). A single-single blind investigation of four auricular needle puncture configurations. American Journal of Chinese Medicine, 23(2), 105 – 114. Margolin A, Avants SK (1999). Should cocaine-abusing, Bupranorphine-maintained patients receive auricular acupuncture? Findings from acute effects study. The Journal of Alternative and Complementary Therapies, 5(6): 567 – 574. Margolin A, Kleber HD, Avants SK, et al (2002). Acupuncture for the treatment of cocaine addiction: A randomized controlled trial. JAMA, 287(1): 55-63. Margolin A, Avants SK, Holford TR (2002). 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Wen HL. Cheng SYC (1973). Treatment of drug addiction by acupuncture and electrical stimulation. Asian Journal of Medicine, 9, 138-141. White AR, Rampes H (1997). Acupuncture in smoking cessation. In: Cochrane Database Systemic Reviews. Oxford. White AR, Resch KL, Ernst E (1999). A meta-analysis of acupuncture techniques for smoking cessation. Tobacco Control, 8, 393 – 397. Yang CY, Kwon YK, et al (2004). Acupuncture attenuates repeated nicotine-induced behavioral sensitization and c-Fos expression in nucleus acumbens and striatum of the rat. Neuroscience Letters, 358(2): 87-90.