Ahlberg et al. Substance Abuse Treatment, Prevention, and Policy (2016) 11:24
DOI 10.1186/s13011-016-0068-z
RESEARCH
Open Access
Auricular acupuncture for substance use:
a randomized controlled trial of effects on
anxiety, sleep, drug use and use of
addiction treatment services
Rickard Ahlberg1, Kurt Skårberg2, Ole Brus3 and Lars Kjellin1*
Abstract
Background: A common alternative treatment for substance abuse is auricular acupuncture. The aim of the study
was to evaluate the short and long-term effect of auricular acupuncture on anxiety, sleep, drug use and addiction
treatment utilization in adults with substance abuse.
Method: Of the patients included, 280 adults with substance abuse and psychiatric comorbidity, 80 were randomly
assigned to auricular acupuncture according to the NADA protocol, 80 to auricular acupuncture according to a
local protocol (LP), and 120 to relaxation (controls). The primary outcomes anxiety (Beck Anxiety Inventory; BAI) and
insomnia (Insomnia Severity Index; ISI) were measured at baseline and at follow-ups 5 weeks and 3 months after
the baseline assessment. Secondary outcomes were drug use and addiction service utilization. Complete datasets
regarding BAI/ISI were obtained from 37/34 subjects in the NADA group, 28/28 in the LP group and 36/35 controls.
Data were analyzed using Chi-square, Analysis of Variance, Kruskal Wallis, Repeated Measures Analysis of Variance,
Eta square (η2), and Wilcoxon Signed Ranks tests.
Results: Participants in NADA, LP and control group improved significantly on the ISI and BAI. There was no
significant difference in change over time between the three groups in any of the primary (effect size: BAI, η2 = 0.
03, ISI, η2 = 0.05) or secondary outcomes. Neither of the two acupuncture treatments resulted in differences in
sleep, anxiety or drug use from the control group at 5 weeks or 3 months.
Conclusion: No evidence was found that acupuncture as delivered in this study is more effective than relaxation
for problems with anxiety, sleep or substance use or in reducing the need for further addiction treatment in
patients with substance use problems and comorbid psychiatric disorders. The substantial attrition at follow-up is a
main limitation of the study.
Trial registration: Clinical Trials NCT02604706 (retrospectively registered).
Keywords: Auricular acupuncture, Psychiatric comorbidity, Randomized controlled trial, Relaxation, Substance abuse
treatment
* Correspondence: lars.kjellin@regionorebrolan.se
1
Faculty of Medicine and Health, University Health Care Research Center,
Örebro University, P.O. Box 1613, SE-701 16 Örebro, Sweden
Full list of author information is available at the end of the article
© 2016 The Author(s). Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Ahlberg et al. Substance Abuse Treatment, Prevention, and Policy (2016) 11:24
Background
The abuse of illicit psychoactive substances and alcohol
is a major worldwide public health problem [1]. In
Sweden, 6 % of the total population have a DSM-IV alcohol abuse and/or dependence diagnosis and 1.4 % of
the population have a DSM-IV diagnosis of abuse of
and/or dependence on illicit substances [2]. Many of
those with an alcohol use disorder also have a drug use
disorder and vice versa. Abuse of a single drug or alcohol alone is relatively rare among patients in substance
abuse treatment [3]. Comorbidity between substance/alcohol abuse and other psychiatric disorders is common
with 50 % having at least one more disorder. Anxiety,
mood disorders and antisocial personality disorder are
the most prevalent comorbid diagnoses [4]. Although
there is some evidence that specific psychosocial interventions (e.g. Cognitive behavioral therapy; [5]) can reduce
problems in patients with single substance use without
psychiatric comorbidity, there is limited evidence to support any one intervention over another in the treatment
of polysubstance abuse with psychiatric comorbidity [6, 7].
Alcoholism has been described at least since the ancient
Greek and Roman times [8]. A wide variety of treatments
for alcohol and drug use problems have been tried and are
used in the standard care of patients with substance
use problems, both pharmacological and psychological
[5–7, 9, 10]. Several alternative treatments have also
been tried, e.g. neurofeedback, art-based therapy, and
eastern influenced treatments like yoga and meditation
[11–13]. One of the more common alternative treatments for substance abuse is acupuncture, in particular
auricular acupuncture. It has been reported that about
seven percent of patients with substance abuse have
tried acupuncture [14, 15]. Over 25 years of clinical experience has supported ear acupuncture and its proponents say it alleviates withdrawal, reduces craving, and
helps retain patients in treatment [16]. A randomized
study by Avant and colleagues found effects of auricular acupuncture on cocaine dependence [17]. However,
several reviews have failed to find support for acupuncture as an effective treatment for substance abuse and
dependence (e. g. cocaine abuse, alcohol dependence,
and opioid addiction), although the poor methodological quality of the studies included has prevented
any firm conclusions to be drawn [18–20]. These large
reviews all suggests that more research on acupuncture
with rigorous and large clinical trials are needed.
In the Swedish national clinical guidelines on substance abuse treatment from 2007 it was concluded that
RCT-studies on acupuncture for substance use problems
had not found any effect above placebo effects but that
there could be effects on other problem areas [21].
White [22] suggested that the lack of effects of acupuncture in clinical trials could be due to the acupuncture
Page 2 of 10
technique used, and the choice of controls and outcome
measures. White found that studies with sham controls
were less likely to be positive than those with nonacupuncture controls, and positive results were more
likely when using measures of craving or withdrawal
than when measuring abstinence. In a systematic review
and meta-analysis of the efficacy of acupuncture for psychological symptoms associated with opioid addiction,
four studies from Western countries did not report any
clinical gains in the treatment of these symptoms. Ten
out of twelve studies from China did however report
positive findings and found a significant difference between treatment groups and control groups for anxiety
and depression associated with opioid addiction. The
methodological quality of the studies included was considered poor [23]. The aim of the present study was to
investigate the effectiveness of two versions of auricular
acupuncture in a large randomized clinical trial. The
main outcome measurements are anxiety and sleeping
problems. Secondary outcomes are alcohol and drug use
and utilization of addiction treatment services.
Methods
Setting and procedure
Data were collected between October, 2010, and June,
2014. Participants were recruited from a substance abuse
clinic for people aged 16 years and above in Örebro,
Sweden—the Addiction Center (AC)—with a catchment
area of around 290,000 inhabitants. The clinic is linked
to the University hospital in Örebro and serves about
880 unique inpatients and 1100 unique outpatients a
year. In order to receive treatment at the AC patients
have to have substance abuse and comorbid psychiatric
problems, assessed and confirmed by psychologist and
psychiatrist assessments and recurrent urine tests.
Treatment at AC involves a mix of social, psychological,
and medical therapies and interventions, e.g. pharmacological treatment in severe cases of depression and anxiety
and for AD/HD and other mental disorders, Antabuse if
required, manual based relapse prevention, Cognitive behavioral therapy, Psychodynamic therapy, Motivational
Interviewing, and support from social workers.
A block randomization schedule with varying block
sizes was created in the statistical software SPSS by a
biostatistician, the third author (OB). The list was used
to place participants who gave informed consent at random into one of three different groups: NADA (National
Acupuncture Detoxification Association)-acupuncture,
local protocol-acupuncture (LP), or control (relaxation).
Based on clinical experience at the AC a larger dropout
was expected among those who were randomly selected
as controls than those allocated to acupuncture. The allocation ratio was NADA 2: LP 2: Control 3. Before start
of patient inclusion, the second author (KS) prepared
Ahlberg et al. Substance Abuse Treatment, Prevention, and Policy (2016) 11:24
envelopes with code number and assigned intervention,
sealed the envelopes and placed them in ascending order
in a box.
Patients were invited to participate in the study by
posters and orally during regular treatment sessions by
receptionists and therapists at all AC units. Those who
expressed interest were given more detailed information
by the acupuncturists in the study, and were told that
participation was voluntary, that the study was a randomized trial, and that the participants would be randomly selected for the usual treatment together with
acupuncture or to be in a control group that would receive the usual treatment and relaxation. Those accepting participation signed a written informed consent
form. The acupuncturist then contacted an assistant
who drew the envelope in turn, opened it and revealed
the assigned intervention. The assistant worked independently and had no other role in the study.
All groups were given self-report questionnaires immediately before the start of the treatment period (T1).
Follow-up post-treatment data collection took place at
5 weeks (T2) and 3 months (T3) after initiation of the
treatment. Patients randomly selected as controls were
offered acupuncture after completing T3. The project
was approved by the Regional Ethics Review Board in
Uppsala, Sweden (Registration number 2010/239).
Interventions
Participants who gave informed consent were randomly
selected for one of three different treatments: NADAacupuncture [24], local protocol-acupuncture (LP), or
control (relaxation). NADA-acupuncture was delivered
in three phases: (1) one treatment each workday during
the first week; (2) three treatments each week during the
following 2 weeks; (3) two treatments each week during
another 2 weeks. The LP-acupuncture was delivered in
two phases: (1) three treatments each week during the 2
first weeks; (2) two treatments each week for the following 2 weeks. This choice of treatment was based on
about 15 years of clinical use of auricular acupuncture,
from which both patients and acupuncturists had reported positive experiences. Relaxation consisted of listening to soft music in a quiet room with dampened
light and was delivered to match the amount and phases
of the LP-acupuncture. Within each group, there was no
variation in treatment. The two acupuncture interventions thus comprised different number of sessions (15 in
NADA and 10 in LP), all carried out individually in a
separate room, but equal treatment: each session consisted of approximately 40 min retention time with acupuncture at five ear points called Sympathetic, Shen
Men, Kidney, Liver and Lung, which are believed to be
the best points for substance abuse patients [25]. Acupuncture was administered to both ears using stainless
Page 3 of 10
steel needles (0,25x13mm). The depth of insertion was
2–3 mm and manual needle stimulation was used. All
three interventions were given as a supplement to treatment as usual (see ‘Setting and procedure’ above).
Twelve male and female acupuncturists, all having gone
through the same national training and thereby certified
in NADA-acupuncture, administered NADA-acupuncture,
the LP-acupuncture, and the relaxation. Their experience
of practicing auricular acupuncture varied from 6 months
to 20 years.
Measurement
Anxiety was measured at treatment start and follow-up
using the Beck Anxiety Inventory (BAI) [26], which has
shown good reliability [27] and validity [28]. Sleep problems were measured at the same time points using the
Insomnia Severity Index (ISI) which has shown god reliability and validity [29]. Alcohol use before treatment
start was measured by the Alcohol Use Disorders Identification Test (AUDIT) [30], and drug use before treatment start by Drug Use Disorders Identification Test
(DUDIT) [31]. AUDIT and DUDIT have good psychometric properties [30, 31]. The Drug Use Disorders
Identification Test-Extended (DUDIT-E) [32], with added
items to measure use of alcohol and anabolic androgenic
steroids, was used in follow-up assessments.
Diagnoses (the main diagnosis recorded closest in time
to start of intervention) according to ICD-10 as well as
data on outpatient visits to a doctor and inpatient treatment episodes at the AC 6 months before and 6 months
after treatment initiation were gathered from the clinical
files. For subjects who were inpatients when treatment
started, the episode in question were counted as an admission before start of treatment while the inpatient
days of this episode were split and entered as either
prior to or after the date treatment started.
Power calculation
A power calculation was performed assuming a clinically
relevant difference between the groups of six BAI units
[33] and a standard deviation of 10.49. Further, a significance level of 95 % and a power of 80 % were used. From
the relaxation group a dropout of 60 % was assumed and
from the two other treatment arms 40 %. The higher
dropout rate from relaxation group was due to an assumption that patients included wanted acupuncture, and
that those who were randomized to the relaxation group
would be more likely to drop out. This resulted in a total
of 315 individuals needed to be included.
Participants
Participants in the study were in treatment for substance
abuse and psychiatric comorbidity at the AC. Both inpatients and outpatients were recruited. Inclusion criteria
Ahlberg et al. Substance Abuse Treatment, Prevention, and Policy (2016) 11:24
were: (1) 18–65 years of age, and (2) ongoing patient
status at the AC. Exclusion criteria were (1) nickelallergy, (2) ear infection, and (3) heart disease. On the
basis of these criteria 280 patients were recruited to
participate in the study and allocated at random to
one of the three interventions. A few patients dropped
out before starting the treatment, and 267 received
their allocated intervention. The flow of participants
in the study is presented in Fig. 1. Data on relapse in
alcohol use or not were obtained from 163 participants
at T2 and 120 at T3, and answers about the use of
other drugs from 153 at T2 and 115 at T3. In many
cases participants gave no reasons for not showing up
to a treatment session or for terminating their participation in the study. In cases when reasons were recorded, the most frequent were illness, followed by
work, lack of time, delay, family reasons, and relapse
into substance use.
Fig. 1 Flow of participants
Page 4 of 10
Statistics
Data were analyzed using the IBM SPSS Statistics for
Windows statistical package, version 22.0. Differences
in categorical variables between patients allocated to
NADA, LP and control respectively were analyzed
using Chi-square tests. Age, number of sessions, and
baseline performance of the three groups on BAI, ISI,
AUDIT and DUDIT were analyzed with Analysis of
Variance (ANOVA). Cases with missing values for up
to three BAI items, one ISI item, two AUDIT items and
two DUDIT items were included in the analyses. In
these cases, missing values were imputed as values
equal to the individual case mean of the completed
items. Due to skewed distributions, service use data for
the three treatment groups were analyzed using the
Kruskal Wallis test. Treatment effects for anxiety and
sleeping problems were analyzed with Repeated Measures Analysis of Variance with time as a within-
Ahlberg et al. Substance Abuse Treatment, Prevention, and Policy (2016) 11:24
Page 5 of 10
intervention, but participants allocated to the longest
treatment, NADA, received, as intended, more treatment
sessions on average than those given acupuncture according to LP or relaxation (Table 1).
When comparing those who completed questionnaires
at T3 (n = 120) with those who dropped out between
randomization and T3 (n = 160), there were no differences
in gender, diagnosis, and BAI, ISI, AUDIT and DUDIT
scores. Participants reassessed at T3 were older (mean [sd]
47.0[13.4] vs. 42.5[13.5], t = 2.77, df = 278, p = 0.006), were
more frequently inpatients (55.8 % vs. 25.0 %, Chi-square =
27.61, df = 1, p < 0.001) and completed more sessions
(mean [sd] 10.0[3.7] vs. 6.9[4.8], t = 5.57, df = 233, p <
0.001) than participants who dropped out before T3.
Outcome data from the baseline and post-treatment
BAI and ISI are presented in Fig. 2 and Table 2. The
interaction effects of group and time in the repeated
measurement ANOVA were not significant, neither in
BAI (F[1.45, 3.13], p = 0.229, η2 = 0.03, NADA decreased
7.2 points between T1 and T3, LP decreased 6.3 points
between T1 and T3 and Control decreased 11.7 points
between T1 and T3) or ISI(F[2.27, 4], p = 0.065, η2 =
subjects factor and group as a between-subjects factor.
Effect sizes were measured using eta square (η2). In order
to look at the in- and outpatients separately a sub-analyses
of repeated measurements ANOVA were preformed
stratified on type of care. Treatment effects for alcohol
and drug use were analyzed using a Chi-square test or
Fisher’s exact test when appropriate. For comparisons of
service use before and after start of treatment respectively,
the Wilcoxon Signed Ranks test was used. P-values <0.05
were considered statistically significant.
Results
Fourtyfour per cent of the participants were women and
their mean age was 44.5 years. The main diagnosis for
more than 50 % of the participants was mental and behavioral disorders due to use of alcohol, and 38 % were
inpatients at the start of treatment. There were no differences between treatment groups at T1 with regard to
gender, age, service use at the AC 6 months before start
of treatment, inpatient status, main diagnosis and BAI,
ISI, AUDIT and DUDIT scores. The mean number of
attended sessions was lower than intended for each
Table 1 Patient characteristics and number of acupuncture or relaxation sessions attended
NADA
Local Protocol
Control
Total
p
n = 80
n = 80
n = 120
n = 280
Female gender, %
37.5
41.3
50.0
43.9
0.185
Age, M(SD)
44.1(14.0)
44.3(14.2)
44.8(13.0)
44.5(13.6)
0.924
Visits to the doctor
1.5(1.7)
2.1(2.0)
1.8(2.0)
1.8(1.9)
0.062
Inpatient admissions
0.7(0.8)
0.9(1.1)
0.7(0.7)
0.7(0.9)
0.406
Inpatient days
2.6(4.6)
3.8(7.8)
3.3(7.3)
3.2(6.8)
0.705
0.333
6 months before start of treatment, M(SD):
Inpatient at treatment start, %
35.0
45.0
35.8
38.2
Main diagnosis, %
n = 73
n = 80
n = 108
n = 261
Mental and behavioral disorders due to:
use of alcohol, F10.1-10.3
52.1
48.8
60.2
54.4
–
use of opioids, cannabinoids, sedatives or hypnotics, F11.1–13.2
23.3
17.5
17.6
19.2
0.649
multiple drug use, F19.1–19.2
15.1
18.8
10.2
14.2
–
Other psychiatric diagnosis, F29.2–90.0
8.2
12.5
11.1
10.7
–
General psychiatric examination, Z00.4
1.4
2.5
0.9
1.5
–
n = 75
n = 74
n = 113
n = 262
21.7(12.5)
19.9(10.8)
21.6(11.9)
21.1(11.8)
n = 75
n = 74
n = 112
n = 261
15.4(7.2)
13.9(7.3)
14.4(6.9)
14.6(7.1)
n = 72
n = 72
n = 109
n = 253
17.3(12.3)
18.6(11.9)
19.0(12.0)
18.4(12.0)
n = 74
n = 71
n = 112
n = 257
10.5(14.5)
10.1(13.8)
9.0(13.2)
9.7(13.7)
n = 68
n = 67
n = 100
n = 235
11.9(4.7)
7.1(3.4)
6.9(3.9)
8.4(4.6)
BAI sum score at T1, M(SD)
ISI sum score at T1, M(SD)
AUDIT at T1, M(SD)
DUDIT at T1, M(SD)
Number of sessions, M(SD)
0.557
0.390
0.637
0.730
<0.001
Ahlberg et al. Substance Abuse Treatment, Prevention, and Policy (2016) 11:24
Page 6 of 10
A. BAI
Beck Anxiety Inventory (BAI) over the three time points
BAI
24
22
20
18
Local protocol
16
NADA
Relaxation
14
12
10
8
Initial
Five weeks
Three months
Time
B. ISI
Insomnia severity index (ISI) over the three time points
ISI
15
14
13
Local protocol
12
NADA
11
Relaxation
10
9
8
Initial
Five weeks
Three months
Time
Fig. 2 Mean scores at T1, T2 and T3 for Beck Anxiety Inventory (BAI) and Insomnia Severity Index (ISI)
0.05, NADA decreased 2.5 units, LP 5.2 units and control 6.0 units). There were significant time effects for
both BAI (F[32.66, 1.56], p < 0.001), η2 = 0.25 and ISI
(F[18.06, 2], p < 0.001), η2 = 0.16. There were no significant group differences (BAI: F[0.57, 2], p = 0.569, η2 =
0.01, ISI: F[0.95, 2], p = 0.392), η2 = 0.02.
When looking at a sub-analysis for inpatients and outpatients separately for BAI neither interaction effect was
significant (for inpatients: F[1.92, 2.86], p = 0.137, η2 =
0.07, outpatients: F[1.06, 3.76], p = 0.383, η2 = 0.05) or
group effect (inpatients: F[0.46, 2], p = 0.636, η2 = 0.02,
outpatients: F[2.55, 2], p = 0.091, η2 = 0.11) but a
significant time effect (inpatients: F[26.59,1.43], p <
0.001, η2 = 0.33, outpatients: F[5.88, 1.88], p = 0.005, η2 =
0.13). For ISI there was a significant interaction effect
for inpatients, but not outpatients (inpatients: F[3.27,
3.94], p = 0.015, η2 = 0.11, outpatients: F[1.16, 3.99], p =
0.336, η2 = 0.06). There was a time effect for both types
of care (inpatients: F[16.47, 1.97], p < 0.001, η2 = 0.24,
outpatients: F[3.61, 2.00], p = 0.032, η2 = 0.09), but no
group effect (inpatients: F[1.98, 2], p = 0.148, η2 = 0.07,
outpatients: F[1.22, 2], p = 0.308, η2 = 0.06).
Around nine to twelve per cent of the participants reported that they had relapsed in alcohol use or used at
Ahlberg et al. Substance Abuse Treatment, Prevention, and Policy (2016) 11:24
Table 2 Mean (standard deviation) raw scores at T1, T2 and T3
for Beck Anxiety Inventory (BAI) and Insomnia Severity Index (ISI)
NADA
Local protocol
Control
BAI
n = 37
n = 28
n = 36
T1
21.4 (14.2)
19.1 (13.2)
22.6 (14.0)
T2
15.1 (12.9)
11.6 (9.0)
10.7 (10.5)
a
T3
14.2 (12.7)
12.8 (13.6)
10.9 (10.6)
ISI b
n = 34
n = 28
n = 35
T1
13.8 (7.8)
14.6 (7.6)
14.2 (7.2)
T2
11.0 (7.3)
13.3 (7.5)
8.8 (8.6)
T3
11.3 (8.9)
9.4 (8.2)
8.2 (7.6)
a
In the repeated measurements ANOVA for BAI the Interaction effect was:
(F[1.45, 3.13], p = 0.229), Group effect: BAI (F[0.57, 2], p = 0.569) and Time effect:
BAI (F[32.66, 1.56], p < 0.001)
b
In the repeated measurements ANOVA for ISI the Interaction effect was:
(F[2.27, 3.94], p = 0.065), Group effect: F[0.95, 2], p = 0.392) and Time effect: BAI
(F[18.06, 1.97], p < 0.001)
least one other drug at T2 and T3. There were no statistically significant differences in this respect between those
who had received NADA-acupuncture, acupuncture according to the local protocol, or relaxation (Table 3).
Comparison of service use at the AC 6 months before
and 6 months after start of treatment, showed that inpatient admissions decreased for all groups while inpatient days increased for both acupuncture groups.
There were no changes in the number of visits to the
doctor for any of the groups (Table 4).
Discussion
The aim of the current study was to investigate the short
and long-term effects of two versions of auricular acupuncture, NADA-acupuncture and a local acupuncture
protocol adapted from the NADA protocol, on anxiety
symptoms, sleeping problems, substance use and addiction service use among psychiatric patients with substance use problems. The two treatment conditions were
compared with relaxation. The results indicate that
symptoms of anxiety and sleeping problems showed
both short and long term improvement. There were no
Page 7 of 10
significant interaction effects for either BAI or ISI, suggesting that improvements in anxiety symptoms and
sleeping problems were comparable across the three
groups and effect sizes were small. Patients in all the
three groups started on average with moderate to severe
levels of anxiety at baseline as rated by the BAI, and all
groups lowered the mean score from T1 to T3 to the
mild to moderate range [34]. Patients in all three groups
started on average at the border of sub-clinical insomnia/moderate insomnia as rated by the ISI, and lowered
to the lowest level of sub-threshold insomnia just above
the score for absence of insomnia [35]. Our findings are
consistent with research showing that non-specific treatment factors and the simple provision of support have
positive effects on psychiatric symptoms [36, 37]. It is
also plausible that some of the effects in all three groups
are effects of regression to the mean [38]. Another possibility is that both acupuncture and relaxation have effects on anxiety and sleeping problems. In a pilot study
of veterans recovering from substance use disorders by
Chang and colleagues, in which study participants were
randomly assigned to acupuncture, relaxation response
training or TAU, it was found that both the acupuncture
and the relaxation groups had greater improvements in
anxiety levels than the TAU group [39].
Those assigned to relaxation in our study did however
not get an actual relaxation training intervention as the
patients in the study by Chang and colleagues mentioned above. The relaxation intervention in our study
consisted of listening to music in a quiet room with a
dampened light. We are not aware of any randomized
studies that have found long-term effects of music listening on anxiety and sleeping problems, and we suggest
therefore that the most plausible interpretation is that
the effects found in our study are non-specific effects.
There are however studies that have found effects of
acupuncture on other outcomes. Stuyt & Meeker [40]
found in a naturalistic study on auricular acupuncture that
patients receiving needles reported significant improvement in anger, concentration and pain management.
Table 3 Relapse in alcohol use and use of drugs at T2 and T3
Relapse in alcohol use, %
T2
T3
a,
Use of at least one drug %
T2
T3
a
NADA
Local protocol
Control
Total
n = 55
n = 43
n = 65
n = 163
12.7
11.6
12.3
12.3
n = 41
n = 34
n = 45
n = 120
7.3
14.7
11.1
10.8
n = 50
n = 41
n = 62
n = 153
8.0
9.8
11.3
9.8
n = 40
n = 32
n = 43
n = 115
12.5
9.4
4.7
8.7
Cannabis, amphetamine, cocaine, opiates, hallucinogenic or other drugs (alcohol excluded)
p
0.986
0.590
0.844
0.442
Ahlberg et al. Substance Abuse Treatment, Prevention, and Policy (2016) 11:24
Table 4 Visits to the doctor and inpatient admissions and days
at the Addiction Center 6 months before and 6 months after
start of treatment
NADA
Local protocol
Control
Total
n = 80
n = 80
n = 120
n = 280
1.5(1.7)
2.1(2.0)
1.8(2.0)
1.8(1.9)
Visits to the doctor
6 months before
6 months after
1.5(1.8)
2.0(2.9)
1.9(3.4)
1.8(2.8)
p
0.651
0.085
0.830
0.365
0.7(0.8)
0.9(1.1)
0.7(0.7)
0.7(0.9)
Inpatient admissions
6 months before
6 months after
0.4(0.7)
0.5(1.2)
0.4(0.7)
0.4(0.9)
p
0.002
0.005
<0.001
<0.001
2.6(4.6)
3.8(7.8)
3.3(7.3)
3.2(6.8)
Inpatient days
6 months before
6 months after
5.9(10.5)
7.3(11.4)
4.3(8.4)
5.6(10.0)
p
0.006
0.010
0.221
<0.001
Mean(standard deviation)
Carter et al. [41] found that NADA-acupuncture had
significant effects on body aches, cravings and energy.
These two studies were non-randomized, limiting the
evidence of actual effects. Chang et al. [39] found significant effects of acupuncture but not of relaxation
on cravings in their randomized study. The acupuncture
group did however receive twice as many intervention
sessions as the relaxation group making the interpretation
of effects difficult.
With regard to substance use, we found no differences
between groups at follow-up. This finding is in agreement with earlier reviews [18–20, 42] who failed to
find evidence of effects on substance abuse following
acupuncture. Only about ten per cent of the patients
in our study reported use of alcohol and/or other
drugs at T3. Those who relapsed in drug use are
probably over-represented among the drop-outs. Another
explanation for the low relapse figures may be that
being drug free is a requirement for receiving treatment
at the AC.
All groups had on average fewer inpatient admissions
during 6 months after start of treatment compared to
before, while the number of inpatient days increased significantly for both acupuncture groups. The increase in
inpatient days for all three groups in aggregate may be
due to the fact that a relatively large proportion of the
research subjects were inpatients when treatment started
and that many of the interventions may have started at
the beginning of the treatment episode. Our sub-analyses
showed that for BAI there were no clear differences
between in- and outpatients in how they change from
inclusion to follow-up and the corresponding effect sizes
were small. For ISI there was such a difference for the
Page 8 of 10
inpatients, but not for the outpatients. Therefore the
change in sleep problems over time among inpatients
seems to differ for the different treatment groups.
The current study has two major strengths. First, the
treatments were implemented with a relatively unselected sample of inpatients and outpatients at a regular
substance abuse clinic, which means that the study participants had high degree of comorbidity and relatively
low adherence to the treatment provided. In other
words, the study probably has high external validity. Second, the study design included three different conditions, one being relaxation/not acupuncture, allowing us
to control partly for non-specific therapy factors (therapeutic alliance, contact time, and treatment credibility)
in the acupuncture conditions. One of the strengths of
the study is also a limitation: patients with substance
abuse and high degree of comorbidity are renowned for
relapses and low adherence to treatment. Fifty-seven per
cent of the patients had dropped out by the time of the
3-month follow-up. Although large dropout rates are
common in trials of interventions for patients with
substance abuse [43], their extent limits interpretation
of the results. In our study, those who dropped out
were younger, more often outpatients and, as expected,
completed fewer sessions than those remaining at T3.
That acupuncture was given individually and not in a
group setting, that few participants actually received
the full amount of acupuncture according to the treatment protocols, and that we do not have data on patients assessed for eligibility and excluded before
randomization are other limitations, but a consequence
of the fact that the interventions were tested in a naturalistic setting.
The imputation method used (mean imputation) assumes that the questions a participant does not answer
would have been answered like those that were answered. Other imputation methods could have been
used, but most imputation methods have the same
problem: they assume that the missing data approximately follows a pattern that in some way follow the
rest of the data.
A further limitation is that we, since patient inclusion
went slower than expected and we did not have funding
to continue, had to finish data collection before we had
reached the number of patients needed according to our
power calculation. Although a larger sample may have
detected statistically significant effects of acupuncture
relative to relaxation training on some of the measures,
the probability of such a finding can be questioned since
the actual changes in BAI and ISI mean scores between
T1 and T3 were greater in the control group than
among those receiving acupuncture. We did not correct
for multiple testing, but given our results, doing so
would not have changed our conclusions.
Ahlberg et al. Substance Abuse Treatment, Prevention, and Policy (2016) 11:24
Conclusions
Bearing the limitations of the study discussed above in
mind, we found in conclusion no evidence for acupuncture
as delivered in this study being more effective than relaxation for problems with anxiety, sleep or substance use or
in reducing the need for further addiction treatment in
patients with substance use problems and comorbid
psychiatric disorders. The failure to find effects of acupuncture over and above the simple provision of music
listening in a quiet environment (the relaxation control
condition) in this randomized controlled trial raises questions about the clinical use of acupuncture in patients
with substance use.
Abbreviations
AC, Addiction Center, Örebro, Sweden; AUDIT, Alcohol Use Disorders
Identification Test; BAI, Beck Anxiety Inventory; DUDIT, Drug Use Disorders
Identification Test; DUDIT-E, Drug Use Disorders Identification Test-Extended;
ISI, Insomnia Severity Index; LP, Local Protocol; NADA, National Acupuncture
Detoxification Association.
2.
3.
4.
5.
6.
7.
8.
9.
Acknowledgements
The authors wish to thank the participating therapists for carrying out the
acupuncture treatments and relaxation and Anna Wadefjord for collecting
case record data.
10.
11.
Funding
The study was funded by Region Örebro County, Sweden. The funding body
had no role in the design, in the collection, analysis, and interpretation of
data, in the writing of the manuscript or in the decision to submit the
manuscript for publication.
12.
Availability of data and materials
As we interpret the ethics approval decision and current national legal
regulations, we don’t find it possible to make our datasets available.
14.
Authors’ contributions
KS, LK and OB designed the study, and KS monitored the data collection. RA
analyzed data and drafted the manuscript. OB and LK participated in the
data analyses and LK helped to draft the manuscript. All authors read and
approved the final manuscript.
13.
15.
16.
17.
Competing interests
The authors declare that they have no competing interests.
18.
Consent for publication
Not applicable.
Ethics approval and consent to participate
The project was approved by the Regional Ethics Review Board in Uppsala,
Sweden (Registration number 2010/239). All participants gave their written
informed consent.
19.
20.
21.
Author details
1
Faculty of Medicine and Health, University Health Care Research Center,
Örebro University, P.O. Box 1613, SE-701 16 Örebro, Sweden. 2Addiction
Center, Faculty of Medicine and Health, Örebro University, P.O. Box 1613,
SE-701 16 Örebro, Sweden. 3Clinical Epidemiology and Biostatistics, Faculty of
Medicine and Health, Örebro University, P.O. Box 1613, SE-701 16 Örebro,
Sweden.
22.
Received: 27 November 2015 Accepted: 28 June 2016
24.
23.
25.
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