JOURNAL OF CHINESE MEDICINE NUMBER 54 MAY 1997

UNDERSTANDING ADDICTION ACCORDING TO TRADITIONAL CHINESE MEDICINE

by Steve Given
Abstract
The role of acupuncture in the treatment of addiction has traditionally been based on the use of acupuncture as if it were a western treatment modality. While this approach has made acupuncture more accessible as a research modality, the subtlety and sensitivity of traditional Chinese medicine has been lost. An examination of the traditional Chinese etiologies associated with addiction and substance abuse necessarily alters our understanding of the pathology and therapeutics of addiction treatment. This failure to employ the principles of traditional Chinese medicine stems from three causes. First, applying acupuncture as a western modality has facilitated the role of acupuncture as a research modality. Second, there has been a movement in the acupuncture detox community towards a simple one size fits all system for the treatment of addiction. Third, there has been little attempt to evaluate addiction in terms of traditional Chinese medicine.

Chinese Medicine Differentiation

Any examination of the theoretical basis of addiction and substance abuse from the viewpoint of traditional Chinese medicine must concern itself both with the overall consequences of drug abuse, and the specific responses to particular drugs. Regardless of which drug is abused, when a substance is consumed at a level that produces significant psychotropic effects, there is an inevitable change in the shen or consciousness. Initially there is euphoria and abnormal exhilaration, whilst continued abuse leads to disturbances of the shen, dream disturbed sleep and insomnia. Positive clinical findings at this stage include a red tongue tip, and the pattern of disharmony corresponds initially to an excess condition of the Heart, and eventually to Heart fire. Chronic abuse usually leads to a condition of tolerance and dependence. Tolerance of a drug is the state where an individuals sensitivity to the drugs effects is diminished, and increasing amounts of the drug must be administered to achieve the desired effects. Dependence is the condition where a patient is psychologically compelled to use the drug, or suffers outright symptoms of illness when the abused drug is not administered. The experience of adverse signs and symptoms following cessation of a drug of abuse, termed withdrawal or abstinence syndrome, results from being dependent on the abused substance for a state of well being. When the substance is withdrawn, symptoms such as anxiety, depression, difficulty in falling asleep and a wiry pulse result. During acute withdrawal, the addict is experiencing symptoms of Liver qi stagnation. During the initial phase of drug use, the drug user is

Introduction
To date, the literature examining the impact of acupuncture on patients being treated for substance abuse and addictionrelated disorders has evaluated acupuncture as if it were an occidental therapeutic modality. The purpose of this paper is to re-examine substance abuse and addiction, and the impact of acupuncture on addiction and addiction-related disorders, from a viewpoint grounded in traditional Chinese medicine theory. By re-examining addiction and treatment from this viewpoint, we place the practice of acupuncture squarely into the paradigm from which it evolved. The literature on acupuncture and substance abuse has fallen into one of three groups. The first group consists of works discussing the impact of acupuncture on the treatment of addiction (Kroening and Oleson, Clavel et al., Lipton et al., Wen and Cheung). The second group consists of works that describe the physiological impact of acupuncture on animals experimentally addicted to some addictive substance, usually an opiate (Ng, Yang and Kwok, Tang and Han, Fung et al., Wen et al.). The last group consists of works that examine the physiological impact of acupuncture on tests subjects (Wen et al., Kendall). In all of these investigations, acupuncture is examined with respect to outcome or mechanism of action from an occidental viewpoint. While much of this work uses controlled studies, such an experimental design is devoid of the principles from which traditional Chinese medicine developed. What is lost is the theoretical underpinning, and the diagnostic and therapeutic subtlety of traditional Chinese medicine.

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motivated by the desired alteration of the shen caused by the drug being used. Once the addict becomes dependent on the drug of abuse, they are trapped in a cycle of withdrawal followed by self-medication after the onset of withdrawal symptoms. In occidental physiological terms, the individual experiences a drop in the blood and tissue concentration of the drug of abuse, leading to the development of abstinence or withdrawal symptoms. When the addict self-medicates, that is self-administers the drug of abuse, the symptoms of withdrawal disappear and are replaced by a sense of well being and euphoria. Of note here is that for many drugs, the addict loses the ability to get high, that is achieve a subjectively attractive alteration of the shen. They use primarily or exclusively to avoid the symptoms of withdrawal, i.e. they use to get well. In terms of traditional Chinese medical theory, this cycle of withdrawal and self-medication moves from Heart excess to Liver excess and back again. Using the addictive substance leads to Heart fire. A drop in the blood level of the addictive substance causes a shift to the Liver qi stagnation.

of the drug user profoundly changes. The role of the strung out or addicted drug user is increasingly the avoidance of Liver qi stagnation. At the same time, the chronic insult to the Heart leads to injury of the Heart qi. Heart qi deficiency manifests with a pale face, shortness of breath, spontaneous sweating, weak pulse, pale and flabby tongue and palpitations. If the excessive sweating injures the yin, the result is yin deficiency. The cycle of Heart fire and Liver qi stagnation is further differentiated according to the type of drug being abused. Cocaine more strongly promotes the development of Liver qi stagnation. Opiates such as heroin, methadone and morphine, often result in shaoyang disharmonies, with chills and fever. Opiates also strongly favor the development of Liver-Spleen disharmony with anorexia, weight loss, diarrhea and bloating, and Liver-Stomach disharmony resulting in nausea and vomiting. While there is some variation in the development of such Liver, Spleen and Stomach symptoms with different addictions, it is important to note that these symptoms develop in all addicts to some extent, and the variation between one drug and another is one of degree.

Some drugs, notably crack cocaine, produce euphoria only initially. The addict spends the rest of her or his using career attempting to replicate that first episode of euphoria or high. In this case, the rapid build-up of tolerance shifts the dynamic of the Heart to Liver oscillation in the direction of Liver excess. The patient subjectively feels this shift in an unscratchable itch, that is a profound need to use that does not return the patient to the remembered Heart excess condition. This patient, unable to get high, resorts to bingeing behavior. Bingeing behavior, that is using a drug constantly or nearly constantly for days or weeks at a time, results in increases in both Heart and Liver excess: the shen is agitated; withdrawal soon returns. Whilst this shift occurs with all addictive drugs, there is some individual variation. The abuse of the crack form of cocaine and benzodiazepines such as Valium very rapidly results in a shift from Heart excess to Liver excess. The abuse of opiates results in a slower change. Regardless of how fast or to what extent this change takes place, the goal

The above patterns of disharmony involving Heart and Liver excess, and Liver overacting on the Spleen and Stomach, are the consequences of a cycle of drug use followed by acute withdrawal. Chronic addiction, however, gives rise to further disharmonies. Chronic addiction, with its long-term Liver and Heart heat, results in Kidney yin deficiency. Several factors exacerbate this yin deficiency. Sweating secondary to acute opiate withdrawal and Heart qi deficiency damages the yin. Diarrhea due to Spleen qi deficiency (as a consequence of Liver-Spleen disharmony) also damages the yin. Yin deficiency may be further exacerbated by fluid and blood loss (e.g. from hemorrhage, childbirth, trauma or surgery) and malnutrition. Malnutrition is an especially prominent cause of deficiency for the addict because many addicts spend available funds on drugs rather than food. Lastly, many addicts are involved in excess sexual activity that damages the Kidney yin. Kidney yin deficiency presents with night

JOURNAL OF CHINESE MEDICINE NUMBER 54 MAY 1997

sweats, malar flush, tidal fevers, thirst, a red tongue with a scanty yellow or geographic coat, and a rapid and thin pulse. Kidney yin deficiency is also associated with low back pain which is especially severe in cases of methadone addiction and withdrawal (methadone is an addictive opiate prescribed for heroin addiction). Kidney yin deficiency occurs more frequently with opiate addiction than in addiction to stimulants such as cocaine.

Deficiency of Kidney yin may result in Kidney yin failing to nourish the Lung or Liver yin. In those patients with Liver excess and Kidney yin deficiency, the deficient yin is no longer able to control the yang, leading to Liver yang rising. Symptoms include anxiety, red eyes, irritability, distending headache, parietal or vertex headache, a wiry, thin and rapid pulse, and signs and symptoms of yin deficiency such as night sweats, malar flush, tidal fever, geographic tongue coat and thin rapid pulse. In this case the yin deficiency is both the result of a Liver heat pattern, and generates deficiency heat of its own that further exacerbates the deficiency and heat. Liver yin deficiency is further exacerbated by the cycle of withdrawal and self-medication. The longer the addict uses an addictive drug, the more the chronic Liver and Heart excess will lead to yin deficiency. The more deficient the yin, the greater the Liver yang rising. This leads to a cycle of positive reinforcement that results in greater and greater Liver and Heart heat and increases severe yin deficiency. The increasing disharmony leads to irritability, anxiety, craving for the drug of abuse, and disturbance of the shen. Clinically, the patient presents with a scorched tongue without coat, malar flush, red eyes, severe night sweats and excessive thirst. The pulse is wiry, thin and rapid. This patient frequently acts out, that is behaves in a potentially destructive or hostile manner, impelled by Liver and Heart excesses magnified by the yin deficiency. It is important to note here that some patients have a propensity to Liver fire, an excess condition that is in many ways similar to Liver

yang rising and which also leads to acting out violent and destructive behaviors. The important factor here is the development of yin deficiency in the patient with Liver yang rising. Lung pathologies in the addict are primarily due to deficiency, and are frequently associated with smoking the addictive drug (see Table 1). Smoking crack (a smokable form of cocaine) gives rise to Lung qi deficiency manifesting as weak cough, weak voice, shortness of breath exacerbated by exertion, frequent colds and infections, a weak pulse and a pale tongue. If the addict has developed yin deficiency, the tongue may be red and geographic rather than pale. Smoking tobacco gives rise to Lung yin deficiency, resulting in an unproductive cough or a cough producing scanty yellow phlegm, night sweats, a dry throat and a hoarse voice. Severe Lung yin deficiency results in hemoptysis. Where the patient is smoking heroin, the primary pattern of disharmony is one of phlegm heat in the Lung. The patient presents with a productive cough, with copious or thick yellow phlegm. Auscultation of the Lungs reveals rhonchi and crackles. This hot phlegm may be associated with Lung qi deficiency or Lung qi failing to descend. The increased likelihood of phlegm production with smoking heroin is due in part to injury to the Spleen and consequent impairment of its ability to transport and transform fluids. This leads to fluid accumulation in the Lung, often in spite of the overall yin deficiency that is developing.

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Chronic drug abuse may damage the Kidney yang as well as the Kidney yin. Drug abuse resulting in chronic Kidney yang deficiency leads to shortness of breath, with difficulty on inhalation. This deficiency asthma pattern is especially common in opiate abusers. Failure of Lung qi to descend in heroin addicts is further complicated by the development of Lung heat conditions in heroin or tobacco smokers. The phlegm and heat block the Lung qi, which fails to descend. When the addict is treated with drugs such as albuterol or theophylline (bronchodilators used to treat asthma), these medications act as strong stimulants resulting in increased anxiety. This medication-related anxiety exacerbates the Liver excess anxiety resulting from the addiction itself. The addict is trapped in a self-perpetuating cycle of increasing use, increasing symptomatology and further increases in use. Injury to the Kidney yang also results in the loss of libido. This loss, as with other patterns described above, is variable depending on the drug being abused. It develops more profoundly with the abuse of depressants, whilst with the abuse of stimulants, especially methamphetamine, the yang is preserved and in the initial stages there is a condition of false yang excess resulting in hyper-sexuality. The abuse of sex that results from the false yang increases yin deficiency which further exacerbates the false yang. In some patient populations, the addiction to and abuse of sex is a primary motivation for the abuse of the drug in question, and these individuals may be addicted to the false yang rather than the Heart excess. Cocaines ability to interfere with the brains neurotransmitters, especially dopamine, alters the neurochemical balance, leading to seizures. Stimulant use is also associated with cerebro-vascular accidents. Spasm, syncope and tremor are associated with interior Liver wind. This wind follows Liver excess, especially where there is heat or phlegm. Phlegm obstructs the Heart orifices, and may be associated with a greasy tongue coat and a rattle in the throat.

Treatment
Clinical practice is based on the idea that pathology follows etiology, and therapeutics follows pathology. If we can differentiate etiology in substance abuse, then we imply that there must be resulting differences in pathology, and that even a patient population as superficially homogeneous on first observation as a substance abusing population should benefit from differentiation in therapeutics. Current clinical practice in the acupuncture detoxification field is heavily based on the use of the same or nearly same protocol for most or all patients presenting to a clinic for treatment of substance abuse related symptomatology. This protocol, consisting of the auricular points Shenmen, Sympathetic, Liver, Kidney and Lung 2 (the lower auricular Lung point) is designed to calm the shen, treat the Liver and Kidney, and treat the vagus nerve (via Lung 2). This is an important point prescription for three reasons. First, the point pre-

scription is very effective in calming the patient, and is an effective means of treating the anxiety associated with drug use and withdrawal. Second, the prescription clearly reduces drug craving for a variety of drugs, enabling the addict to resist the urge to continue to use a substance, a primary issue in addiction and recovery. Third, the prescription supports the Liver and Kidneys and related organ systems, reducing the signs and symptoms of drug use and withdrawal. This protocol is promoted by the National Acupuncture Detoxification Association (NADA), is described in literature on acupuncture and detoxification (Oleson, Brumbaugh), and is the standard of practice in the acupuncture detoxification community. Brumbaugh suggests that at least in the early phase of treatment, the point prescription should not be altered. It is necessary to question, however, whether the addict is best being served by such a limited armamentarium, or would efficacy be improved by a differentiation based on the traditional Chinese medical interpretation of the signs and symptoms? Clearly, an appreciation of the subtlety of traditional Chinese medicine suggests that some differentiation, even under the limited conditions of a detoxification clinic, would improve efficacy and clinical outcome. Listed in Table 2 are the NADA protocol (referenced above) and possible modifications of the NADA protocol. While this point list is not exhaustive, clearly these points can be used to develop a treatment model deriving from the NADA protocol. These modifications could be the result of pattern differentiation using the principles described previously. Table 3 shows additional auricular points that can

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be used to modify the basic auricular detoxification formulas in Table 2. They are chosen on the basis of the patient's signs and symptoms. These additional auricular points could also be selected based on whether they are sensitive to palpation, or have a lower transdermal electrical resistance than the surrounding auricular tissue, implying that they are active and will therefore have a therapeutic impact. These points are described by Oleson in his International Handbook of Reflex Points.

Conclusion
The purpose of this article is not to question the undeniable efficacy of acupuncture detoxification as it is currently practised. The NADA based work has done a great deal to lessen suffering and promote sobriety in the addiction community. The questions rather are: i. what is the traditional Chinese medical basis of addiction; ii. can we re-examine the etiology, pathology and therapeutic basis for addiction based on the principles of traditional Chinese medicine; and iii. what could the impact of this re-examination be on the therapeutic tools used by the acupuncturist in the treatment of addiction? Clearly, we have a firm basis for differentiating the addict based on traditional Chinese medicine. While the above discussion is by no means definitive, there is in it the beginning of a differentiation based on the pattern of dis-

harmony. There is a strong correlation between the specific drug of abuse and the array of patterns of disharmony associated with the state of addiction. This differentiation suggests some changes in therapeutics based on the pattern of disharmony. Such differentiation and treatment modification could be successful even in the limited treatment setting of the detoxification clinic, with the patients sitting in a communal treatment room fully clothed. It has been this authors experience that some of these modifications are quite feasible (see Table 4). Where the pattern of disharmony has determined a specific modification of treatment, the efficacy of treatment has been enhanced by treating this pattern, rather than simply directing the treatment at the monolithic entity of addiction.

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Acknowlegements
The author would like to acknowledge David Chan, O.M.D. and Susan Morse, M.T.O.M. for their suggestions in the preparation of this manuscript. Steve Given, L.Ac., Dipl.Ac., is the acupuncturist at the Hollywood clinic of the Bay Area Addiction, Research and Treatment (BAART) clinics, where he specializes in the treatment of HIV and substance abuse. Steve is the Clinic Director and Western Sciences Department Chairman at Emperors College, and is on the faculty of Samra University and Yo San University.