NADA A simple but effective tool to aid in the opioid epidemic. Libby Stuyt, MD

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2 WELCOME

3 NADA A simple but effective tool to aid in the opioid epidemic Libby Stuyt, MD

4 Session Description The National Acupuncture Detoxification Association (NADA) 5-point ear acupuncture protocol is a simple tool that can help break the vicious cycle of trauma, pain, and addiction. It is a drug free, client centered, low cost, safe and effective intervention that can help patients calm down enough to cope, allowing them to be more active participants in other areas of treatment. It can aid in the management of stress, cravings, sleep, pain, and drug withdrawal, improving treatment retention and outcomes.

5 Session Objectives 1 Recognize the vicious cycle that occurs from trauma resulting in chronic pain; using opioids without addressing the underlying emotional trauma and how this contributes to ongoing addictive behavior. 2 Describe a simple 5-point ear acupuncture protocol that can aid in breaking the cycle and how it can help with opioid withdrawal and treatment retention. 3 Plan how to be trained to use this tool and how to incorporate it as an aid in treating addictions, stress, PTSD, and psychological and emotional trauma.

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8 Acupuncture for Addiction Treatment Initially discovered by Dr. Wen in 1972 neurosurgeon in Hong Kong found serendipitously that electrical stimulation of an ear point used as preoperative anesthetic abated physical withdrawal of opium He then published successfully treating 40 heroin-and opium-addicted individuals (Asian J Med 1973;9: ) 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. NYT article

9 NADA history The 1970 s in the South Bronx, New York was a time of a rampant opioid epidemic and social unrest Lincoln Hospital developed a Methadone Detox program one of the first of its kind The impoverished community of the South Bronx was looking for improved treatment services as part of the social justice movement, they wanted more natural, non-pharmaceutical approaches

10 NADA history Michael Smith MD and colleagues adopted Dr. Wen s method and over several years, with input from the clients, they added other ear points In addition to lung point they added Shen Men (spirit gate), and points for the sympathetic nervous system, kidney and liver. They dropped the electrical stimulation and found that manual stimulation was more tonifying, producing a more prolonged effect.

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12 NADA The National Acupuncture Detoxification Association was founded and incorporated in 1985 by Dr. Smith and others to promote the training of behavioral health clinicians The term acudetox was adopted to differentiate it from other forms of acupuncture Lincoln was the largest training institute for Acupuncture Detoxification Specialists (ADS) and people came from all over the world to be trained until it closed in 2011

13 Use of NADA spread by word of mouth Primarily because there was no money behind it (as in pharmaceutical aids to treatment) The use of acudetox has evolved and has been found to be a useful tool in substance abuse treatment as well as - Drug courts/behavioral courts - Mental health - Trauma - Chronic pain management

14 Western Medicine Perspective The effectiveness of acupuncture in the treatment of substance abuse and mental illness is difficult to study. It is difficult to study this treatment modality in a controlled/blinded fashion Some placebo-controlled studies have suggested acupuncture shows promise for treating cocaine, heroin, alcohol and nicotine dependence as well as depression and anxiety.

15 Use in Alcohol Dependence (Bullock et al. 1989, Lancet, ) placebo-controlled study in severe recidivist alcoholics - 40 patients received auricular acupuncture using three treatment points (sympathetic, Shen Men, and lung points) 40 patients received sham acupuncture with three nontreatment points (<5mm from treatment points).

16 Use in Alcohol Dependence (Bullock et al. 1989, Lancet, ) 21 of 40 patients in the treatment group completed the program compared with only 1 in 40 of the control group. At six-month follow-up - more patients in the control group expressed a moderate to strong need for alcohol, had more than twice the number of drinking episodes and admissions to detoxification centers.

17 Use in Heroin Dependence (Washburn et al. 1993, J Sub Abuse Tx,10, ) 100 heroin-addicted adults (not in methadone treatment) randomly assigned Treatment group- needles in four treatment points (sympathetic, Shen Men, kidney and lung points) Control group - needles in sham points, geographically close to standard points but not thought to be specific for addiction.

18 Use in Heroin Dependence (Washburn et al. 1993, J Sub Abuse Tx,10, ) Subjects receiving the standard treatment for addiction attended the clinic more days than subjects in the sham group and were more likely to return for additional treatment beyond the 21-day detoxification period.

19 Use in Cocaine Dependence (Avants et al. Arch Int Med. 2000;160: ) Eighty-two, cocaine-dependent, methadone maintained patients were randomly assigned Auricular acupuncture using 3-5 points (sympathetic, Shen Men, kidney, lung and liver) Sham acupuncture (needles inserted subcutaneously at four points along the helix) No-needle relaxation control.

20 Use in Cocaine Dependence (Avants et al. Arch Int Med. 2000;160: ) Analysis of longitudinal urine toxicology data indicated NADA auricular acupuncture protocol was significantly more effective in reducing cocaine use than either the relaxation control (P=.01) or the needle insertion control (P=.05). Patients who completed the 8-week course of acupuncture abstained from cocaine significantly longer during treatment and were more likely to be abstinent at completion than either of the control conditions (P<.05).

21 Large, Multi-Site, Randomized, Single Blinded Clinical Trial (Margolin et al. JAMA 2002;287:55-63) 620 patients in six sites throughout the US They found that the NADA protocol was not more effective than sham or relaxation control in reducing cocaine use Concluded: The NADA protocol is not a stand alone treatment for cocaine addiction Sadly this was a water shed moment where much NADA research and application stopped

22 Analysis of what happened Margolin, Avants and Holford J Altern Complem Med. 2002;8(2): Cash incentives rewarding attendance, not abstinence - Financial incentives - $2 after each treatment session and $10 each week for 2 sessions and 3 urines no matter whether positive or negative Elimination of coping skills therapy group - Counseling sessions poorly attended

23 Use of Auricular Acupuncture in Smoking Cessation (Beir et al. Am J Pub Health 2002;92: ) Compared the NADA protocol alone to the NADA protocol plus smoking cessation education to sham acupuncture plus the smoking cessation education Combination of acupuncture plus education and counseling 40% cessation, compared to 22% for sham plus education and counseling to 10% for acupuncture alone NADA is not a stand-alone procedure

24 Colorado Mental Health Institute at Pueblo Circle Program 90-day, inpatient, dual-diagnosis treatment program for men and women, 18-65, treating people who have failed everything else 75-80% admitted as Condition of Probation Funded by the State of Colorado Abstinence based Intense, cognitive/behavioral program Totally tobacco free since 2000 Using NADA acudetox since 2000 Axis II disorders 75% (includes marked traits)

25 Study of All Patients Treated From January 2001 December 2003 (Stuyt and Meeker, J Dual Diagnosis, 2006;2:41-52) 440 patients treated Overall 246 or 56% successfully completed the program stayed the recommended time in treatment, completed all assignments, no major rule violations resulting in premature discharge LOS for successful completers 86 ± 13 days LOS for those unsuccessful 38 ± 23 days

26 Use of Auricular Acupuncture 367 or 83% of the patients participated in auricular acupuncture 61% of patients getting needles successfully completed versus 32% of those who did not receive needles p=< LOS for those receiving needles = 70 ± 26 days versus 39 ± 34 days for those who did not receive needles p<0.0001

27 Number of Sessions For the 367 patients receiving needles, those who successfully completed the program participated in significantly more needling sessions completers with 12 ± 7 sessions non-completers with 8 ± 5 sessions - p<0.0001

28 Variables That Do Not Predict Use of Auricular Acupuncture Gender no difference (p=0.605) Race no difference (p=0.619) Primary Drug no difference (p=0.749) Primary Psych Dx no difference (p=0.382) Axis II Dx no difference (p=0.224) Age no difference (p=0.930) Tobacco use no difference (p=0.999)

29 Attitude Regarding Use of Tobacco After Discharge Predicts successful completion rates For those planning to smoke ASAP - 41% successfully completed program For those who wanted to stay quit - 80% successfully completed program p<0.0001

30 Use of Acupuncture Helps Those Planning to Smoke and Those Wanting to Stay Quit For those planning to smoke ASAP, significantly more successfully completed the program if they had 8 or more sessions - 57% versus 24% with <8 sessions p< For those planning to remain quit, significantly more successfully completed if they had 8 or more sessions - 90% versus 69% with <8 sessions p<0.05

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32 Patients Receiving Needles Reported More Overall Improvement Than Those not Receiving Needles Severity of Symptoms Change in Severity of Overall Symptoms Over Five Weeks of Auricular Acupuncture Treatment Beginning and End of Treatment p=.0003 Controls N=21 Acupuncture N=75

33 Severity of Symptoms Severity of Cravings Decreased for Both Groups Change in Severity of Cravings Over Five Weeks of Auricular Acupuncture Treatment Beginning and End of Treatment p=.9329 Controls N=21 Acupuncture N=75

34 Severity of Symptoms Severity of Drug Using Dreams Decreased for Both Groups Change in Severity of Using Dreams Over Five Weeks of Auricular Acupuncture Treatment Beginning and End of Treatment p=.7699 Controls N=21 Acupuncture N=75

35 Symptoms of Depression Improved for Both Groups Severity of Symptoms Change in Severity of Depressive Symptoms Over Five Weeks of Auricular Acupuncture Treatment Controls N=21 Acupuncture N= Beginning and End of Treatment p=.1498

36 Severity of Symptoms Symptoms of Anxiety Improved for Both Groups Change in Severity of Anxiety Symptoms Over Five Weeks of Auricular Acupuncture Treatment Controls N=21 Acupuncture N= Beginning and End of Treatment p=.2679

37 Severity of Symptoms Anger Symptoms Improved Only in Group Receiving Needles Change in Severity of Anger Symptoms Over Five Weeks of Auricular Acupuncture Treatment Beginning and End of Treatment p=.0014 Controls N=21 Acupuncture N=75

38 Severity of Symptoms Patients Receiving Needles Reported Significant Improvement in Concentration Change in Severity of Concentration Symptoms Over Five Weeks of Auricular Acupuncture Treatment Beginning and End of Treatment p=.0007 Controls N=21 Acupuncture N=75

39 Severity of Symptoms Patients Receiving Needles Reported Significantly Less Problems with Sleep Change in Severity of Sleep Symptoms Over Five Weeks of Auricular Acupuncture Treatment Beginning and End of Treatment p=.0027 Controls N=21 Acupuncture N=75

40 Patients Receiving Needles Reported Improvement in Pain Symptoms Severity of Symptoms Change in Severity of Pain Symptoms Over Five Weeks of Auricular Acupuncture Treatment Beginning and End of Treatment p=.0365 Controls N=21 Acupuncture N=75

41 Patients Receiving Needles Reported Feeling Significantly More Energetic Severity of Symptoms Change in Severity of Energy Symptoms Over Five Weeks of Auricular Acupuncture Treatment Beginning and End of Treatment p=.0461 Controls N=21 Acupuncture N=75

42 Auricular Acupuncture for Dental Anxiety: A RCT (Karst et al. Anesthesia and Analgesia 2007;104: ) 67 patients randomized to auricular acupuncture, placebo auricular acupuncture and intranasal midazolam Assessed for anxiety and sedation No differences between auricular acupuncture and intranasal midazolam could be detected Anxiety-reducing effects started as early as 30 minutes after insertion of needles or application of midazolam Duration of sedation less prolonged in the acupuncture group

43 Cost-effectiveness in substance abuse treatment RP Santasiero et al. Med Acupuncture 2005;16: patients treated with NADA, 22 without, all received treatment as usual in an outpatient HMO chemical dependency program At 6 months follow-up the acupuncture group had - Higher program completion (74% vs 44%) - Higher rates of negative urines (96% vs 85%) - Fewer inpatient rehab days (39 vs 57 days) - Cost incurred for acupuncture group = $15,580 - Cost for non-acupuncture group = $17,890

44 Trials of acupuncture for drug dependence: a recommendation for hypotheses based on the literature White, A. Acupunct Med 2013;31: Systematic review: 48 studies (included body points, other protocols), manual and electrical stimulation Difficult to compare studies due to multiple variables in protocol/measures/controls Studies with sham acupuncture controls less likely to be positive (33%) than those with non-acupuncture controls (75%) (80% for NADA studies with non-acupuncture controls) Continued use by providers despite unsupportive evidence means mismatch

45 2012 SAMHSA National Survey Only 628 of 14,311 programs surveyed reported using acupuncture (4.4%) Source: Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration, National Survey of Substance Abuse Treatment. Services (N-SSATS), 2012

46 Integrated Health Pilot Project, Portland, Oregon excellent example of integrating NADA in pain management Initiated to treat patients in a family practice with behavioral health conditions and pain Integrated clinical team with PCP, acupuncture both NADA and full body, and behavioral health Treatment may consist of one on one therapy, group therapy based in either CBT or DBT, acupuncture, and medication management for psychiatric disorders. Medication not initiated nor maintained without client participating in other parts of the project Acupuncture and NADA is covered by Medicaid

47 Veteran s Integrative Pain Center, Hunter Holmes McGuire, VA, Richmond, VA Orthopedic medicine Auricular acupuncture Medical acupuncture Medication management Movement reeducation: Tai Chi and QiGong Peer support Pain Education Care management Physical therapy Individual and Group Psychotherapy to treat pain and comorbid conditions

48 Auricular Acupuncture Daily Drop-in auricular acupuncture group Meets noon daily for 60 minutes Utilize Mental Health group rooms with comfortable seating and background music Trained providers may utilize NADA protocol during individual sessions when appropriate Reported by Maggie Roma ANP-BC, VA Clinic Administrative Coordinator at the 2014 NADA conference

49 Veteran Testimonials I simply sleep better when I attend group that day I haven t noticed anything after I leave, but I like being in the room during that hour My wife insists that I come because I m different at home that night I m less anxious. I need to be here This almost works like a drug. I came in here miserable with a tension headache and now it s gone

50 NADA in Trauma/Abuse/Chronic Pain NADA has been found to be very helpful for people experiencing extreme trauma natural disasters, terrorist situations - Fires, floods, earthquakes, tsunamis - Shootings, bombings Addiction is often a trauma-based illness with patients experiencing multiple complex trauma/abuse throughout their lives and using substances to numb

51 Discovery of the benefit of NADA in Trauma After the terrorist attacks at the World Trade Center 9/11/2001 an acudetox stress reduction clinic started in Manhattan at St. Vincent s Hospital Over 1,000 treatments in the first 10 days, the clinic continued until 2007, funded by the Red Cross People reported that it helped them sleep and calm down enough to cope Used around the world in disaster situations - Acupuncturists Without Borders - Colorado Acupuncture Medical Reserve Corp

52 Important to recognize that trauma and subsequent psychological disorders can contribute to chronic pain There is a high prevalence of psychological comorbidities among patients with chronic pain The presence of pain may cause emotional distress and exacerbate premorbid psychological disorders Emotional problems may increase perceived pain intensity, disability and perpetuate dysfunction Unrecognized and untreated psychological distress may interfere with successful treatment of chronic pain

53 NADA with Borderline Personality Disorder Patients with borderline personality disorder have frequently experienced multiple traumas/abuse growing up and frequently use drugs to cope. People with borderline personality disorder in substance abuse treatment very often have difficulty in treatment leaving prematurely Many professionals find them very hard to work with NADA can be the treatment of choice with this population

54 Personality disorders and retention in therapeutic community for substance dependence Samuel DB et al. Am J Addictions, 2011;20: evaluated the impact of 10 personality disorders on early attrition (within the first 30 days) as well as time to dropout during a 9-month therapeutic community residential treatment program BPD was the only personality disorder negatively related to overall program retention.

55 Impact of borderline personality disorder on residential substance abuse treatment dropout among men (Tull MT & Gratz KL, Drug and Alcohol Dependence 2012;121:97-102) Patients with borderline personality disorder (BPD) are significantly more likely to prematurely drop out of substance abuse treatment This study focused on males 159; 34 with BPD Found that BPD significantly predicted treatment dropout (38.2% versus 16% of those without BPD) Particularly true in center initiated treatment dropouts (26.5% versus 6.4%, p<0.01)

56 Circle Program Mandated to treat the people who have failed all other treatments High incidence of people with personality disorders as well as chronic pain issues Patients are frequently abusing opioids in addition to other drugs We have found that NADA actually does aid with opioid withdrawal symptoms and aids detox

57 Outcome Study Stuyt, EB. Ear acupuncture for co-occurring substance abuse and borderline personality disorder: an aid to encourage treatment retention and tobacco cessation. Acupunct Med. 2014;32: January 2009 December patients admitted - 55% male - 88% using tobacco daily - 74% condition of probation/parole/diversion, 6% civil commitment, 20% voluntary 80% completed the three month program 86% of the 179 eligible enrolled in the year long followup after treatment

58 Program Completion Remain the recommended time in treatment Complete all plan of care assignments Move up through the level system In 2000 the program completion rate was 56% In 2011 the program completion rate was 80% Being tobacco free improves outcomes Addition of alternative treatments like NADA improve retention and ability to cope

59 Characteristic Category Completed Program N = 185 (80%) Did Not Complete N=46 (20%) P value Gender Male Female 99 (78%) 86 (83%) 28(22%) 18 (17%).4104 NS Race Caucasian Hispanic African-American Asian 148 (82%) 26 (76%) 9 (64%) 2 (100%) 33 (18%) 8 (24%) 5 (36%) 0 (0%).3492 NS Age Years ± SD Range 36 ± ± NS Primary Drug Dependence Diagnosis Alcohol Polysubstance Methamphetamine Cocaine Opiates Cannabis 65 (84%) 54 (76%) 28 (82%) 20 (83%) 12 (80%) 6 (60%) 12 (16%) 17(24%) 6 (18%) 4 (17%) 3 (20%) 4 (40%).4898 NS

60 Characteristic Category Completed Program N = 185 (80%) Did Not Complete N=46 (20%) P value Primary Psychiatric Diagnosis Bipolar D/O Other Affective D/O PTSD Other Anxiety D/O Psychotic D/O Substance Induced Other 31 (78%) 42 (82%) 55 (82%) 24 (86%) 13 (59%) 12 (86%) 8 (89%) 9 (22%) 9 (18%) 12 (18%) 4 (14%) 9 (41%) 2 (14%) 1 (11%).4834 NS Tobacco Use On Admission Yes No 159 (78%) 26 (93%) 44 (22%) 2 (7%).08 NS

61 Characteristic Category Completed Program N = 185 (80%) Did Not Complete N = 46 (20%) P value Legal Status Tobacco Use in treatment Criminal Commitment Civil Commitment Voluntary Yes No 146 (85%) 7 (47%) 32 (71%) 36 (67%) 149 (84%) 25 (15%) 8 (53%) (29%) 18 (33%) 28 (16%).0092 Tobacco Use plan for after treatment Wants to stay quit Plans to use tobacco Ambivalent 143 (93%) 32 (48%) 10 (7%) 35 (52%) < (91%) 1 (9%)

62 Factors aiding program completion Having a probation officer and accountability - 85% on probation completed - 71% of the voluntary patients completed - 53% of civil commitments completed - p=.0013 NADA acudetox appears to help with program completion - Those completing had 12 ± 9 acudetox sessions - Those not completing had 5 ± 5 sessions - p<.0001

63 Focusing on those with personality disorders Of the 231 patients - 78 had borderline personality disorder - 37 had antisocial personality disorder - 49 had no personality disorder or marked personality traits 98% of those with no Axis II diagnosis successfully completed program 87 % of those with BPD completed (13% dropout) 59% of those with ASPD completed (41% dropout)

64 Use of NADA acudetox by Personality

65 At the end of the year follow-up of 140 patients there were no differences between: Gender (p=.855) Race (p=.459) Primary drug dependence (p=.737) Primary psych diagnosis (p=.78) Tobacco use prior to admission (p=.604) Legal status (p=.062) Presence of Axis II diagnosis (p=.387)

66 Status at the end of the year follow-up for 140 patients 60% 54% 50% 40% 30% 20% 16% 24% 10% 3% 3% 0% Sober and doing well Relapsing Back in treatment Deceased Incarcerated

67 Patient with BPD did just as well as others without BPD by year s end

68 Tobacco use was significantly correlated with relapse Non-tobacco use increased from 14% to 27% at the end of the year. Those using tobacco were much more likely to relapse. (p=.01) Those continuously abstinent were more likely to not be using tobacco. (p=.03) For those who relapsed to drugs or alcohol - 9 ± 5 months to first relapse for non-tobacco user - 6 ± 5 months to first relapse for tobacco user (p=.008)

69 Those with Borderline PD were more likely to quit tobacco use after treatment

70 For all 140 patients Those not using tobacco at the end of the follow-up period participated in significantly more NADA acudetox sessions when they were in treatment (15±9) Than those who were still using tobacco (12±8) p=0.04

71 So Why Is NADA helpful in BPD? Patients with BPD usually come from a back ground of chaos; they think this is their normal and will seek to create chaos when it doesn t exist, to feel normal They benefit from grounding techniques to experience a new normal anything to increase the parasympathetic tone is helpful

72 Use of NADA with BPD Start with NADA 5-point ear acupuncture protocol - Immediate calming effect - Allows the patient to learn what it is like to sit still - Helps with transference and counter-transference They are then more open to learning dialectical behavioral therapy (DBT), mindful meditation, biofeedback, tapping, yoga, Tai Chi, progressive muscle relaxation, etc.

73 Animal Model for NADA - support for why it can help with opioid addiction and chronic pain Kailasam, Anand and Melyan. Establishing an animal model for National Acupuncture Detoxification Association (NADA) auricular acupuncture protocol. Neuroscience Letters. 2016;624: NADA can reduce morphine-induced locomotor sensitization in rats (comparable to cravings in humans) and prevents the development of morphine tolerance in rats. NADA also aided the earlier onset of analgesia from morphine.

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76 How to add NADA to your treatment program National Acupuncture Detoxification Association Not-for-profit training and advocacy organization Yearly conference with week-long preconference training 120 registered trainers throughout the USA and Canada 70 hour training didactics, NADA spirit, and 40 supervised treatments certificate of training

77 Who can be trained? Depends on state laws 21 states have some sort of NADA exemption for expanded scope of practice, rather than being limited to acupuncturists or physicians(carter K, Olshan- Perlmutter M. NADA Protocol. J Addict Nurs. 2014;25: ) Some states have very strict supervisory and scope requirements that limit the accessibility of this protocol

78 COLORADO LAW - PERFORMANCE OF AURICULAR ACUDETOX BY TRAINED MENTAL HEALTH PROFESSIONALS SB law change to expand the scope of practice of the NADA protocol to include: - Licensed psychologists - Licensed social workers - Licensed professional counselors - Licensed addiction counselors, CACIIIs - Marriage and Family Therapists - Registered psychotherapists

79 How NADA is used in Colorado Substance abuse treatment programs Community Mental Health Centers Community Health Care Clinics Federally funded integrated health care clinics Hospice Hospital Emergency Rooms Cancer Centers Private practice therapists

80 Process Improvements and Take-Aways To learn more about the NADA protocol and acudetox contact the National Acupuncture Detoxification Association NADA The website can give you information about your state law to determine if you can practice this protocol in your state You can find trainer contact information and trainings on the website or through the office The NADA office/board performs advocacy and education to help if you are interested in changing the law in your state to expand the scope of practice for this protocol The NADA office can link you with NADA treatment providers who have developed policies and procedures and credentialing processes

81 Continuing Education Certificate and Evaluation Process To receive Continuing Education (CE) credits for approved educational sessions, you must: Have your attendee badge scanned at the beginning AND at the end of each session. Attend each session in full. Complete the CE process within 45 days of the end of the event. Ensure you are able to receive messages from Login to the CE-Go website using the personal you received from CE-Go. Verify all of the sessions you attended. Complete the evaluation form for each session you attended. Download your Continuing Education Certificate for your records. If you have any questions regarding this process, please contact CE-Go at or

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