Opioid Crisis and Acupuncture
Opioids are analgesic medications: that is, they are used in the treatment of pain. Their use is not without risk. What is the opioid crisis? Could there be a simple solution to the complex problem of the opioid crisis?
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Risk of Overconsumption and Dependence
Opioid medications can cause euphoria (or high), which can lead to overconsumption. A patient taking opioid medications for pain may or may not experience euphoria. However, all opioids can create dependence. The term dependence alludes to the compulsive use of a substance, despite its harmful effects. People with a personal or family history of substance abuse, including alcoholism, are more likely to develop dependence on opioid analgesics.
Over the past ten years, overconsumption of opioid analgesics and dependence on them have become a public health problem. Overconsumption can have serious health effects on the user, even leading to death from overdose. Drug overconsumption and dependence on any substance can also cause problems at work and school, and lead to family breakdown. Drug overconsumption can further result in costs to society, particularly with respect to healthcare, crime, and loss of productivity." -Health Canada
A Public Health Problem...
And for good reason. In 2016 alone, 2,816 deaths were recorded, approximately 8 per day in Canada. (1a) In 2017, 3,987 deaths were reported. An increase of more than 30% compared to the previous year. In 2017, 8 out of 10 cases involved men, predominantly in their thirties. The Public Health Agency suggests that illegally sold street fentanyl is still a factor. (1b) Although the total number of opioid prescriptions in 2017 decreased for the first time since 2012, Health Minister Ginette Petit Pas Taylor noted that the crisis is also explained by "high rates of opioid prescriptions." Canada ranks among the top globally for per capita opioid use from 2005 to 2015. From 1990 to 2015, opioid use in Canada increased by 1,677%. (PPSG)
https://www.youtube.com/watch?v=Yg4huoEh2_4
In response to the opioid crisis, several versions of white papers internationally now collectively propose a non-pharmacological approach to pain treatment. This is the case with authors who collaborated internationally on the preparation of this white paper in late 2017 (2a), which proposes acupuncture as a solution to address opioid overprescription and overdoses associated with this medication. In a second white paper published in December 2017 (2b), the non-pharmacological approach that tops the list for pain treatment—you've guessed it, which is why I'm telling you about it—is acupuncture! Acupuncture is a safe treatment with rapid action, provided it is administered by a properly trained acupuncturist!
Indeed, the opioid public health crisis is heading into an unprecedented dead end. Without a real turning point, what will prevent this social crisis from continuing to worsen? Between 2001 and 2016, the number of opioid-related deaths in the United States increased by 345%. The population most affected: millennials, ages 24-35. (3)
It has been demonstrated that overdoses are also linked to higher prescription rates. Professor Steve Morgan from UBC (University of British Columbia) states: "our study shows that these prescription medications are used in ways that create significant harm to the population." (4) Heather Morgan, UBC, regarding the same publication: "These findings would demonstrate a need for change in prescription practices and monitoring of total opioid sales."
A New Paradigm⚡
Refer to acupuncture. Pain treatment itself can be accomplished to a large extent through acupuncture. The new paradigm proposed here does not exclude performing standard diagnostic procedures to identify the cause of pain when necessary. Some cases require a multidisciplinary approach; an integrative approach should be prioritized. Physicians can now develop the reflex to refer patients to acupuncturists when it comes time to treat pain. This is a reasonable option within the framework of evidence-based medicine (EBM) practice.
Isabelle Gaboury and colleagues attempt to answer an important question. Their publication, released in 2016 in the journal Canadian Family Physician, is titled: Regarding alternative and complementary medicines: Do physicians consider themselves able to meet the requirements of the Collège des médecins du Québec? (5)
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"There is a gap between the knowledge perceived by Quebec family physicians regarding alternative and complementary medicines and the advisory role they must assume to fulfill their legal and deontological obligations established by the CMQ, which aim to protect the public. The results therefore argue in favor of better exposure of physicians to alternative and complementary medicines during their initial training and continuing education." -Isabelle Gaboury et al.
The public must also know that acupuncturists are first-line providers. It is therefore not always necessary to consult your physician before beginning acupuncture treatment. Your acupuncturist will know how to guide you if your case warrants multidisciplinary management.
In the context of the opioid crisis in the United States and political pressure from the American administration, the American College of Physicians sets an example in early 2017 by publishing clinical guidelines regarding the treatment of acute, subacute, and chronic low back pain. An integrative, non-medication approach is recommended and promoted. For example, acupuncture is included in the recommendations for all types of low back pain, while laser is included in recommendations for chronic low back pain.
States, Municipalities and Counties Demand Accountability from Pharmaceutical Industry ⚖️
Chicago started the ball rolling in 2014. Since then, the Mayor of New York followed suit in 2018. They are not alone. This is a national campaign. Bill de Blasio, Mayor of New York, expresses himself in these terms: "The time has come for Big Pharma to pay for what has been done." The lawsuit, filed in Manhattan Supreme Court, alleges that the opioid crisis was caused by misleading marketing by manufacturers and abusive distribution by distributors. All of this allegedly forced the city to spend millions of additional dollars on rehabilitation programs, hospital services, pre-hospital emergency services, and law enforcement. Costs borne by public institutions sometimes include the burial of individuals who died from overdose, as well as care for orphans left behind by this disaster.
The list of plaintiffs does not end there. Also included are the City of Seattle, Everett, the State of Washington, Indianapolis, Cincinnati, Dayton, Lorain... West Virginia has already won 2 cases, totaling $40 million USD in compensation.
"The industry not only aggressively pushed opioids to physicians, it minimized—and in some cases completely failed to disclose—the dangerous and addictive nature of the medications in question. At the same time, the benefits of the medications were exaggerated." -Attorney Pete Holmes, who leads the lawsuit for Seattle>
"The Dayton lawsuit extends the scope of liability to include individual physicians who acted as consultants to manufacturers, engaging in promotion and covert marketing to patients.">
"...46 states and local attorneys worked together to sue the tobacco industry in 1998. At that time, their efforts paid off. The tobacco industry ended up paying more than 200 billion in settlements for selling addictive and dangerous substances. The pharmaceutical industry could be next..." -Sarah Holder, City Lab
ACUPUNCTURE
Acupuncture is effective, rapid-acting, cost-effective, and safe in the treatment of pain.
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https://www.youtube.com/watch?v=0uhdRtSdL7o
Acupuncture in the Treatment of Acute Pain
Is treatment of acute pain with acupuncture possible in the emergency department? According to a study published in the American Journal of Emergency Medicine in 2016, acupuncture is more effective, safer, and faster-acting than intravenous morphine. The researchers also note that acupuncture treatment was better tolerated by patients than medication. (630422-3/fulltext))
And What About Chronic Pain?
Treatment of chronic pain with acupuncture presents extraordinary cost-effectiveness: the effects of acupuncture are durable. According to the meta-analysis by MacPherson, H. et al., published in the journal Pain in 2017, 90% of the benefits of acupuncture treatments for chronic pain would be retained 12 months after intervention (7)
The update by Andrew J. Vickers et al., published in May 2018 in The Journal of Pain30780-0/fulltext), supports the notion that the persistence of acupuncture's effects 1 year after treatment administration is significant. Only a 15% reduction in acupuncture's effects would be observed 1 year after treatment. This difference in persistence of effects observed by MacPherson would be due to the inclusion of data related to chronic neck pain.(830780-0/fulltext)) Patients suffering from chronic neck pain may need more frequent adjustments than those suffering from other types of chronic pain.
Could this be attributable to the fact that more than 60% of the world's population now uses mobile devices, negatively affecting posture?
* Me and my mobile, sitting in a tree, K.I.S.S.I.N.G.
Key points highlighted in Vickers et al.'s publication:
**"- Acupuncture has clinical effects on chronic pain that persist over time
- The effect of acupuncture treatment cannot be explained by the—reductive—phenomenon of the placebo effect...
- Referral for acupuncture is a reasonable option for patients suffering from chronic pain''
"Acupuncture is now recommended for numerous health disorders involving chronic pain. Despite evidence supporting its effectiveness, acupuncture is often misunderstood and probably underutilized in mainstream settings. A critical review of its effectiveness, practical integration, and mechanisms of action is essential for the current medical community continuing to seek therapies other than opioid medication to address chronic pain. Evidence has accumulated significantly regarding acupuncture's effectiveness in treating chronic low back pain, neck pain, shoulder pain, knee pain, as well as headaches. Additionally, emerging data support the use of acupuncture as an adjunctive or alternative treatment to opioids, also in the perioperative context.''(9)
A Spectacular Application of Acupuncture
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#Acupuncturists #acupuncture #acuponcture #Montreal #montreal #kungfu #panda
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A post shared by Clinique Shanti (@cliniqueshanti) on March 9, 2017 at 2:31 PST
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Acupuncture Anesthesia
Acupuncture allows for the reduction of analgesic medication required for surgical procedures. Perioperative acupuncture can reduce nausea and promote recovery.
Electroacupuncture
Electroacupuncture (electroacupuncture) consists of adding electrical stimulation to acupuncture needles. This is a variant of acupuncture treatment, commonly used in acupuncture clinics.
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A post shared by Clinique Shanti (@cliniqueshanti) on March 16, 2018 at 3:12 PDT
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Mechanisms of Acupuncture
A study conducted by the US Department of Veteran Affairs highlighted the reintroduction of stem cells stored in bone marrow into circulation following electroacupuncture treatment.
This release of stem cells into the bloodstream has been demonstrated in humans, rats, mice, and horses. We now know that stem cells, increasingly studied for their various clinical applications, would play an important role in the regeneration of living tissues, regulation of inflammatory processes, pain management, and more. (10)
A schematic representation of the mechanisms of action of electroacupuncture in the treatment of persistent pain is proposed by Ruixin Zhang et al. in the publication entitled Mechanisms of Acupuncture–Electroacupuncture on Persistent Pain. Lund & Lundeberg present in 2016 a current synthesis of systemic mechanisms of acupuncture treatment. (11) (12)
1. Peripheral effects:>
a. Release of adenosine (removes pain from your muscles) b. Release of nitric oxide (positive effect on the circulation of your blood)>
2. Spinal effects (modulation of motor reflexes and sympathetic nervous system activity, which allows you to move)>
3. Modulation of endogenous systems (namely what allows pain inhibition by releasing natural pain relievers produced by your body)>
4. Changes in functional brain connections (electricity is transmitted differently in your brain: it's electrifying, sometimes even permanently.) Central integration allows activation of limbic structures involved in stress and disease, the hypothalamic-pituitary-adrenal axis, the prefrontal and frontal cortex...
A systematic review on the effect of acupuncture on resting state fMRI in 574 subjects, all considered healthy, documented acupuncture's influence on functional brain connectivity networks in the following regions: the anterior cingulate cortex, left anterior cingulate cortex, left posterior cingulate cortex, right anterior insula, limbic-paralimbic-neocortical regions, precuneus, brainstem, cerebellum, as well as subcortical and hippocampal brain regions.
5. Restoration of default mode network (DMN) (the brain regions that light up when you enter your rest zone, or when you forget that the world is watching and you're in your bubble)>
6. Modulation of parasympathetic nervous system activity (this is the part of your nervous system that likes to keep you in party mode: eating, drinking, relaxing, vegetating, and sleeping)>
7. Activation of mirror neurons and reward system (thinking about throwing a ball and throwing a ball: pretty much the same thing for your neurons)*>
8. Modulation of immune system activation (this is a good thing. immunity maintains a healthy barrier with your environment)>
9. Effects on expectations, attention, conditioning, and extinction of conditioned responses'' (therapy in silence)>
-Irene Lund, Thomas Lundeberg (with additional commentary)
Let us add to this list the recent discoveries concerning acupuncture's ability to modulate purinergic signaling, particularly related to the adenosine mentioned above. (13) For a discussion concerning acupuncture's anti-inflammatory mechanisms, I invite you to read this article.
The needle would also allow for rearrangements in the extracellular matrix, which translates into a reduction of mechanical stress on surrounding connective tissues. The reduction of constant stimulation of mechanoreceptors would then reduce discomfort and chronic myofascial pain.
From a fundamental perspective, it is difficult to overlook the electromagnetic modeling explaining the medical technology of the traditional acupuncture needle. Additionally, a "new" organ discovered in 2018, named the interstitium, has sparked discussions in the scientific community. Dr. Neil Theise, the lead author of the study highlighting possibly the largest organ in the human body, commented that the structure of the interstitium could serve as an internal medium for transmitting the targeted bioelectricity of the acupuncture needle. In fact, the interstitium corresponds to the tissue level at which acupuncture needles are typically inserted. The movement of the interstitium's protein bundles would be responsible for electrical current. The biostimulation operated by acupuncture needle intervention would act on this current.
Endogenous Opioids Released by Acupuncture Treatment ✊
Low-Frequency Electroacupuncture (Hz)
Low-frequency electroacupuncture would stimulate the release of β-endorphin, enkephalin, and endomorphin, EM1, EM2, activating mu (μ) and delta (δ) opioid receptors (14)
Stimulation at 2 Hz affects mu (μ) and delta (δ) opioid receptors; stimulation at 2-15 Hz combines the action of mu (μ), delta (δ), and kappa (κ) opioid receptors in the spinal cord.
High-Frequency Electroacupuncture (Hz)
High-frequency electroacupuncture would stimulate dynorphin, which activates the kappa (κ) opioid receptor, which may play an important role in treating opioid withdrawal syndrome.
Stimulation at 100 Hz accelerates the release of dynorphins, which is why it is used clinically for opioid withdrawal syndrome, particularly to relieve associated depression and anxiety. (15) (16)
Combination of frequencies is possible in clinical practice. It allows for achieving maximal therapeutic effect, confirmed by clinical trials targeting various chronic pain conditions. (17)
Acupuncture would also act through the diffuse noxious inhibitory control (DNIC) pathway, a nerve-mediated inhibitory pain relief mechanism, controlled by aminergic neurotransmitters (serotonergic neurons) and opioids (18)
Enkephalin and endomorphins would act more on immediate pain relief, while endorphins would require 20 minutes to be generated and released.
Potency
Dynorphin-(1-13) is a potent opioid peptide. Dynorphin would be 700X more potent than enkephalin, 200X more potent than normorphine. (19)
The potency of acupuncture treatment is probably the reason it is commonly used to treat pain, but also withdrawal syndrome from various psychotropic substances, including opioids. Withdrawal may require multidisciplinary management.
What Patients Say About Acupuncture
In Quebec:
In 2017, 1,000 patients responded to a survey conducted by the Association of Acupuncturists of Quebec (AAQ)
• 92% of surveyed patients reported positive results following their treatments>
• 75% of respondents completed fewer than 15 acupuncture treatments, with nearly half receiving fewer than five treatments...>
• 95% of patients indicated they would consult an acupuncturist again if the pain or symptoms for which they were treated returned." -AAQ
In the United States:
In a retrospective study surveying a network of 89,000 patients, 93% of American respondents reported that the acupuncturist successfully treated their chief complaint. (20)
Public Safety ⚠
If you live in Quebec, for your safety, make sure to consult an acupuncturist who is a member of the Order of Acupuncturists of Quebec (OAQ) to receive acupuncture treatment. This ensures you are dealing with a healthcare professional with solid initial training. An acupuncturist member of the OAQ adheres to a specific code of ethics and is responsible for completing regular continuing education throughout their career to improve their clinical skills.
One of the reasons it is better to be an acupuncturist to use acupuncture needles: they work fully when piercing acupuncture points, indeed! Researchers measured a biomarker, nitric oxide (NO), to reach the conclusion that acupuncture's genuinely positive effect on blood circulation manifests fully when properly piercing acupuncture points. (21)
Immunity
In addition to risks related to overuse, dependence, and overdose, opioid consumers are exposed to a phenomenon of immunosuppression. This translates into increased risk of developing serious infections. Thus, an American study published in Annals of Internal Medicine found that opioid exposure constitutes a risk factor for invasive pneumococcal disease (invasive pneumococcosis). The association is even more significant if it involves long-acting, high-potency opioids used at high doses. (22)
Conversely, acupuncture promotes modulation of immune system activation. This has a positive impact on immunity, as demonstrated notably in acupuncture treatment of anxiety, pain, allergies, tissue lesions, infected tissues, and more.
Immune System and Inflammation
Acupuncture's anti-inflammatory actions via reflex stimulation of the central nervous system also act through the innate immune system. It has been demonstrated that electrical stimulation of the vagus nerve modulates, for example, macrophage activation and the production of TNF-α, IL-1beta, IL-6, IL-18, and other pro-inflammatory cytokines...(23)
In pain treatment by acupuncture, it has been demonstrated notably that 30 minutes after an acupuncture treatment, most patients show a significant increase in CD3, CD4, and CD8. Monocyte activity also increases for half of patients 30 minutes after treatment begins and for all patients 24 hours after treatment. Natural Killer cells (NK) were also increased in nearly half of patients...(24)
Immune System and Anatomical Particularities of Acupuncture Point Location
Mast cells and nerve cells would share perivascular anatomical locations (around blood vessels). These 2 types of cells, mast cells and nerve cells, would be found in abundance at the anatomical location of acupuncture points. Peripheral stimulation by acupuncture of these specific points induces histamine release by mast cells. Histamine excites receptors in primary sensory neurons and leads to a nerve impulse. Histamine released at an acupuncture point would play a key role in the response to acupuncture.(25)
Other Common Options Examined More Closely
Non-Steroidal Anti-Inflammatory Drugs (NSAIDs)
NSAIDs are products commonly used without prescription to relieve pain. They can also be prescribed. According to a meta-analysis published in 2017, which reviewed data from 40,000 patients, there would be
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