mandag, 25-10-2021

Peter R. Martin: Historical Vocabulary of Addiction

 

Acupuncture

 

       According to the current electronic version of the Oxford English Dictionary (OED), the noun acupuncture is a borrowing from the Latin acupunctura which is derived from the classical Latin acū and the post-classical Latin punctura.  The former is the ablative of acus needle, which is from the noun acicula as used in Zoology and Botany (“A slender spine, prickle, or other needle-like structure; [in polychaete annelids] a chitinous rod forming an internal support for a parapodium”).  The later is derived from the classical Latin punct-, the past participial stem of pungere (“to prick, puncture, [of insects] to sting, in post-classical Latin also to cause to smart”) and the suffix -ūra (“action or process, the result or product of this”).

       The noun puncture is the modern derivative, meaning “penetration by a pointed object…, wound made by perforation, pricking sensation or pain…, compunction.” According to OED, The noun puncture has its “first element being after Japanese hari needle (8th century), acupuncture needle (11th century), acupuncture (late 16th century) and also (written with the same kanji) shin- needle.” There are multiple other references related to acupuncture in OED, such as moxibustion (Alternative Medicine: “The therapeutic practice of burning moxa or another substance on or next to the skin.”) in both Chinese and Japanese.

       The definition of acupuncture in OED is: “A method of medical treatment, originating in China, in which fine needles are inserted into the skin at specific points on the body surface; the performance of this.” The definition continues: “Acupuncture, used in China for several thousand years, became the object of scientific study in the west in the latter part of the 20th century, and is now increasingly accepted as a therapeutic technique by western physicians, especially for pain relief.”  This supports the relevance of acupuncture as a potential treatment of addiction through its evolving connection to pain and various other co-occurring disorders.

       The first use of the word in the English language via translation appeared in the compendium A guide to the practical physician by Theophile Bonet (1620-1689).  Known as the Physician of Geneva (Anonymous 1969), Bonet wrote a yearbook of medical practice compiled from reports sent to him by physicians of the day which included observations and recent discoveries in the basic sciences.  He quoted Willem ten Rhijne (1647–1700), a Dutch physician and botanist who was sent by the Dutch East India Company in 1674 to the trading post Dejima in Japan where he collected materials on Japanese medicine, especially on acupuncture and moxibustion: “Among themselves, they [sc. the Japanese] have, by the guidance of China, adapted a two-fold method of Cure to the foresaid Diseases, namely, Acupuncture [L. acuum puncturam], and burning with their Moxa” (Bonet 1686).

       Daniel Turner (1667–1740), an English physician who started his medical career as a surgeon/barber and subsequently was awarded the the first ever M.D. degree in the U.S. in 1723 by Yale College (Anonymous 1970), published the first English textbook on dermatology, De Morbis Cutaneis.  In this book he argued that surgeons/barbers, who for centuries had been relegated by physicians to treating external diseases, should be given the right to administer internal medicines as well, since the medicines they were applying externally to the skin were also producing internal effects.  Acupuncture, no doubt, represented an illustration of this inconsistency to Turner — a “surgical” technique with the potential to treat illnesses that are typically viewed as “medical” problems:  “A great Part of the World, viz. China and Japan, give very few, and those very simple ones, laying their chief Stress, and undertaking to cure almost all Distempers, by Acupuncture and Inustion” (Turner 1723). 

       According to the understanding of physiology in Asia, specific external body locations are linked with body organs by pathways called meridians along which vital energy, or qi (chi), is said to flow and each of a set of twelve such pathways are associated with specific organ systems (Lawson-Wood 1959).  In health, flow of vital energy along these meridians is in a dynamic balance of opposing, interdependent qualities, namely the yin and yang, whereas disturbances of this balance result in disease.  It has been held for millenia that disease could be alleviated by restoring the balance of vital energy by stimulation, usually by needle insertion or by other means, of specific locations along the relevant meridians.  According to Chen (2011), mechanistic understanding of pain, especially the symptoms and signs of nociceptive and inflammatory pain, as an imbalance of yin and yang that could be restored by treatment has been central in traditional Chinese medicine, first described in the 3000-year old medical book Huang Di Nei Jing.  

       Scholars of medicine in the West were well aware of these therapeutic techniques and quite ambivalent about their efficacy as suggested by an editorial in the Edinburgh Medical Surgical Journal (Anonymous 1827):

       “Those of our readers who have perused the essay of Mr Churchill on acupuncture [James Morss Churchill (1796—1863) was a British physician, surgeon and botanist who wrote the first article on acupuncture in England (1821)]… and who are aware that investigations have been lately made on the same subject in various parts of the Continent, may be surprised that hitherto no notice has been taken of it in this Journal.  One reason has been, that the first accounts given of the virtues of the new remedy were so marvellous, and therefore seemed to savour so much of quackery, that, coming, as they did, from persons not of the highest authority, we could not but follow the general example, and decline giving implicit credit to their assertions. But these assertions have been re-echoed from almost every quarter of Europe; observations have been made on the subject at many continental schools of eminence; the several accounts given by unconnected writers agree very remarkably in every essential particular; the alleged facts have at length been put to the test of a full and minute train of experiments by one of the most scientific of the Parisian physicians, in a great public hospital, and under the eyes of its pupils; the results of these experiments, as published by his hospital assistants, harmonize exactly with the statements made by those who introduced the remedy into Europe; and under such circumstances we cannot any longer delay presenting a summary of the interesting information which has been accumulated in its favour.

       “It must be confessed, however, that after all we cannot approach this singular topic without hesitation.  It is true, that, in the hands of M. Cloquet (Jules Germain Cloquet [1790–1883]), a French physician and surgeon who was a skilled artist and anatomist with a keen interest in alternative medical practices such as mesmerism and acupuncture (Morand 1825), the remedial virtues of acupuncture have passed triumphantly through an ordeal, to which no remedy, whose claims were false, could be submitted without detection.  But, at the same time, the utmost ingenuity of its favourers has been unable to discover, in a long course of minute inquires, any rational way of accounting for its effects; and, what is perhaps of more consequence, they have been unable to detect any physiological change or phenomenon co-ordinate with its operation.  There is in short a total want of every sort of evidence in its favour as a remedy, except that most treacherous kind, the evidence of succession; and consequently, a philosophical mind, especially considering the diseases in which the greatest success has been obtained, will naturally feel inclined to attribute the cures which have been accomplished to the influence of the imagination, and to sentence acupuncture to banishment from regular practice, as being nothing else than a variety of animal magnetism.”

       All the same, there continued to be tremendous historical and philosophical interest in the contributions of acupuncture as the mainstay of traditional Chinese medicine to Asian understanding of the role of Man in the Universe (Veith 1962).  

       To be accepted as reputable treatment in Western medicine, the putative benefits of acupuncture for treatment of pain and other distressing conditions required that the technique be reconceptualized within a compatible construct of the structure of the body (Detwiler 1929) and of the sensory transmission of pain in the nervous system (Brown-Sequard 1859), which were distinctly different from ideas in Asia.  Additionally, as mentioned above, a dichotomy of interests and tension between practitioners of surgery and medicine (Stienen, Scholtes, Samuel et al. 2018) may also have contributed to why it has been so challenging to establish objective evidence for efficacy of acupuncture and to accept its role in healing in the West.

       Although Western fascination with Chinese medicine has been longstanding (Penfield 1963), widespread interest in the therapeutic potential of acupuncture in the United States seems to date to an article in the July 26, 1971 edition of the New York Times in which the columnist James Reston described his experience with acupuncture anesthesia during his surgery for acute appendicitis while in China.  Subsequently, as part of President Nixon’s rapprochement with China influential American physician groups began visiting that country.  Curiosity was generated in the capacity of acupuncture to manage pain and this provided the impetus for understanding this technique within the traditions of Western medicine.  Opinions at this time about acupuncture varied widely, but mostly the technique was viewed as no more than placebo-like in its actions, akin to hypnosis, and effective mostly in “strong reactors” (Mann 1974; Gaw, Chang and Shaw 1975).  In short order, scientists developed explanatory anatomic and physiological theories for acupuncture that were compatible with Western scientific principles and its lexicon (Melzack and Wall 1965; Dornette 1975; Watkins and Mayer 1982). 

       The interest in acupuncture for treatment of drug use disorders originated from the role of this technique in the field of anesthesia (Cheng and Ding 1973) and early reports in high quality scientific journals that electro-acupuncture, indeed, did elevate pain threshold in the great majority of patients (Andersson, Ericson, Holmgren and Lindqvist 1973).  The mechanistic relationship between pain and addiction received further support from the reported effectiveness of acupuncture for treatment of opioid withdrawal (Tseung 1974).  The potential for therapeutic efficacy of acupuncture in addictive disorders seemed a hypothesis worthy of investigation as the pathogenesis of addiction and pain are profoundly interdigitated and because treatment of addiction was on a less solid footing in Western medicine than that of many other disorders (Martin, Weinberg and Bealer 2007).    

       Initial experience with acupuncture resulted in a position paper from a professional organization that concluded the technique was not a reputable medical treatment (National Council Against Health Fraud 1991).  In response to this controversy concerning the efficacy of accupuncture, the National Institute of Drug Abuse (NIDA) conducted a technical review of the role of acupuncture in the treatment of alcohol and drug use disorders (McLellan, Grossman, Blaine and Haverkos 1993).  The NIDA committee identified a need to clarify and define the terms and methodologies of acupuncture in an operational manner before robust research was possible.  (These issues related to standardization of the acupuncture techniques are not dissimilar from research in all treatment approaches practiced in medicine—whether pharmacological, surgical or psychosocial.)

       Moreover, the committee proposed defining with greater granularity the goals of acupuncture treatment with respect to the clinical course of alcohol and drug use disorders —whether the treatment was intended for detoxification (initial phase of treatment, lasting 3-7 days after stopping use, when a patient is suffering from direct effects of the abused substance), rehabilitation (the second stage of treatment, typically lasting 15-90 days, beginning after the completion of detoxification/stabilization) or relapse prevention (the third stage of treatment, beginning near the end of the rehabilitation phase, with the goals to maintain the gains achieved in the earlier phases of treatment and to actively develop strategies to avoid relapse). 

       Over the years, there have been reports of employing acupuncture in treatment of many drug use disorders and Moner (1996) concluded  that efficacy of the technique is “very encouraging” as it has positive attributes of being “quick, inexpensive, and relatively safe” so that “acupuncture treatment may establish itself as an important addition to addiction services in the future.”  Accordingly, acupuncture has been viewed by most as an integrated adjunct to the pharmacopsychosocial elements of addiction  treatment (Martin, Weinberg and Bealer  2007) rather than as a stand-alone medical/psychiatric/surgical technique which can “cure” the disorder.

       Consistent with this complementary role, acupuncture has been demonstrated to have broader therapeutic effects than analgesia alone, including treatment of insomnia, depression and anxiety (Spence, Kayumov, Chen et al. 2004; Lee, Kim, Kim et al. 2020; Yu, Wei, Chang et al. 2021), symptoms that are mechanistically interconnected with alcohol and drug use disorders and contribute to morbidity of these conditions (Martin, Weinberg and Bealer 2007).  Moreover, acupuncture has been reported to possibly benefit behavioral addictions like overeating manifested as obesity (Zhong, Luo, Chen et al. 2020). 

       The mechanism of action of acupuncture and related techniques is thought to be based on frequency of electrostimulation resulting in stimulation of the release of diverse neuropeptides such as endorphins, neuropeptide Y, oxytocin, substance P, neurokinin, (Han 2003).  β‐endorphin, endomorphin and encephalin are released with low frequency electrostimulation, which then interact with mu‐opioid receptors and delta‐opioid receptors as supported by antagonism of these effects with naloxone.  By contrast, high‐frequency electroacupuncture (100 Hz) accelerates the release of dynorphin, which binds preferentially to kappa‐opioid receptors.  

       Acupuncture has been found to have a somatotopic distribution in its release of brain-gut peptides and anti- and pro-inflammatory responses in the rat, including in a model of Parkinson’s disease (Liu, Wang, Su et al. 2020; Yu, Min, Bai et al. 2020).  As research progresses, acupuncture has been reported to activate a remarkable number of neuroreceptors and neuromediators involved in pain control and related physiological actions (Trento, Moré, Duarte and Martins  2021), suggesting the potential for important, though not yet harnessed, therapeutic effects.

       Similar caveats that were voiced over the past two centuries have continued in recent years as studies of the role of acupuncture in management of alcohol/drug use disorders and a plethora of medical/surgical/psychiatric conditions have continued.  Advances in neuroimaging studies have allowed dissection of brain mechanisms involved in the therapeutic actions of acupuncture by determining connectivity among specific limbic brain regions in depressed humans (Duan, He, Pang et al. 2020).  The consensus seems to be that there is significant efficacy compared to placebo/sham conditions but the quality of the available evidence remains low and the therapeutic potential of acupuncture warrants further investigations as a “promising” adjunctive treatment for alcohol/drug and related disorders. 

       Of course, the question that must be answered is whether these data are any different from other widely used components that comprise an integrated pharmacopsychosocial approach to addiction treatment.  At this stage, it is predicted that there may be a particular role for acupuncture in treating stimulant use disorders and possibly behavioral addictions, especially for those for which there are no current good pharmacological approaches available (Gates, Smith and Foxcroft  2006; Kim, Zhao, Lee et al. 2020; Ronsley, Nolan, Knight et al. 2020; Yang, Yao, Wang et al. 2020; Zhong et al. 2020).

 

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June 17, 2021