The Opioid Epidemic and Restorative

Justice: The NADA Auricular

Acupuncture Protocol
October 24, 2017 @ 9:30 a.m.
Kenneth Carter, M.D., M.P.H.
Yvette Marie Miller, M.D.

The Opioid Epidemic and Restorative Justice: National

Acupuncture Detoxification Association (NADA) Protocol
A Tool for Recovery in Opioid and Co-Occurring Disorders

Kenneth Carter, M.D., M.P.H.

Medical Director
SalusCareFlorida Emergency, Acute Care & Residential Services
Fort Myers, FL
kcarter@saluscareflorida.org

Yvette Marie Miller, M.D.

Executive Medical Officer
American Red Cross, Donor and Client Support Center
Charlotte, NC
yvette.miller@redcross.org

1
 Session Objectives

Examine the history of NADA Protocol in relation to addiction and treatment

Learn how to integrate the NADA protocol into in a variety of settings including hospital and
community based centers.
Examine evidence based research for efficacy of NADA auricular acupuncture in treating
patients with addictions and other behavioral health conditions.

Restorative Justice Practices:

Focus on Ear Acupuncture
The John Marshall Law School Restorative Justice Project

https://youtu.be/4KV7uLJetR8

2
 NADA Video
https://www.youtube.com/watch?v=7C
7NzqB7p3s

NADA Video

3
 NADA Video CN2

https://youtu.be/66wz
ODcSGr0

NADA Video-CN2

4
 Why auricular acupuncture
 In 1962, only 2% of the US population over the
age of 12 years had tried an illegal drug
 By the mid 1980s, nearly 50% of the population
had experimented with an illegal drug
 The annual number of persons with substance
dependence or abuse in 2013 (21.6 million)
 Similar to the number in each year from 2002
through 2012 (ranging from 20.6 million to 22.7
million)
2013 National Survey on Drug Use and Health (NSDUH), U.S. Substance Abuse and Mental Health Services
Administration (SAMHSA);

What is NADA
 A nonprofit organization established in 1985

 Multidisciplinary membership
- 30% acupuncturists
- Many other specialties including social workers,
psychologists, physicians, CACs, mental health
technicians, EMTs, MRCs

5
 The NADA Organization
 Educates providers, stakeholders and policymakers
 Provides manual guided certification for NADA
trainees
 Maintains bank of official Registered Trainers
 Provides administrative guidance through National
NADA Office, Executive Director, and website
support

Understanding the ear

 Paul Nogier—Central Figure
• France, early to mid 1950’s
• Systematic exploration and charting of entire ear using
ohm meter
• Inflammation in the body mapped in corresponding
areas of the ear by measuring change in electrical
resistance on surface of the ear
• 92% correspondences btw foci of established body
pathological and ear measurements

6
 The First Peer Reviewed Report
 China, 1972—Dr. Wen’s anecdotal
observation
• Treating pain in neurosurgical
patients post surgery using
electrostimulation to bilateral ear
Lung points
• Observed patients reporting
amelioration of opiate withdrawal

Lincoln Recovery Center Adopts Ear

Acupuncture
 At first, copied Dr. Wen’s Formula

--Electro-acupuncture

--Lung point only

Wen, H. L. (1973). Treatment of drug addiction by acupuncture and electrical

stimulation.

7
 NADA Auricular Protocol

 Is best positioned as adjunctive therapy that

“clears the field” for more specific treatment
 Can be administered to individuals but is best used
in a (communal) group setting
 Provides balancing (homeostatic) and centering; Is
not allopathic in nature or intention

NADA 1974 to Present:

An Organic Clinical Process
 Lincoln Hospital started by Dr. Michael Smith to address the
heroin epidemic in NYC in the 1970s
 Experimentation to identify auricular points: Lung and
Shenmen
 Lung – associated with analgesia, sweating, and respiration.
Lower half of ear innervated by vagus nerve.
 Shen Men - Regulates excitation and inhibition of the cerebral
cortex and can produce sedation. mental clarity
 Sympathetic: Regulate disruption in both sympathetic and
parasympathetic nervous systems.
 Kidney point: help methadone patients with edema
 Liver point: help liver function and inflammation

8
 Why the Ear?
2 to 5 weeks

Why the ear?

Embryonic Development

• Embryonic gill plates develop into the

external ear and are comprised of tissue
from all 3 embryonic layers
• ectoderm
• mesoderm
• endoderm
External ear is the only body structure where
all 3 embryonic layers are represented.

9
 Why the ear?:
Embryonic Development

 Early development
• Regulatory systems basic to all life
• Vegetative systems basic to all life
• Gill plates become the ear

 Later development
• Central Nervous System
• Autonomic Nervous System
• Hypothalamic Pituitary Axis (HPA)

External ear-- Spinal Cord Connections

• Ectodermal—helix and lobe.

• Principal innervation via greater auricular
nerve of the superior cervical plexus (C 1, C
2, C 3).
• Mesodermal—base and upper pinna.
• Principal innervation via auriculotemporal branch
of the anterior superior trigeminal nerve (C 5)
which has sympathetic fibers.
• Endodermal—concha
• Principal innervation via auricular branch of the vagus
nerve (C X) which has sympathetic fibers.

10
 Microsystem Correspondences
 External ear is one of many microsystems used to
guide traditional Chinese medicine interventions.
Other microsystems include e.g., radial and carotid
pulses, tongue, face.
 Microsystems range from very simple to highly
complex including the motor cortex and thalamus

Millennial Chinese Texts

on
Ear Correspondences

 Su Wen and Ling Shu

• Both say, “Yin meridian channels
converge on the ear, Yang meridian
channels pass through the ear”
 Suggestive of the ear as having unique potential
for Yin/Yang [Parasympathetic/Sympathetic?]
balance

11
 Other Mechanisms:
Electromagnetic Theory
 Charge particles moving through space create
electromagnetic waves.
 All minerals, sugars, proteins, RNA, DNA, etc., exist
in the body as charged particles and impact the ear
proximally and distally by generating
electromagnetic waves
 Electromagnetic waves result in focused standing
waveform patterns that impact/generate
somatotypic regions

Other Mechanisms:
Specific Physiologic Effects
 Blood Flow
 Breathing Rate
 Endogenous peptides [eg, beta endorphin,
metenkephalins,
 Neurotransmitters [eg serotonin,
norepinephrine, dopamine and cortisol]
 Brewington, V. et al. Acupuncture as a detoxification treatment: A analysis of
controlled research. Journal of substance abuse treatment11[4], 298-307
 Smith M O, Carter K O, et al. Ear acupuncture in addition treatment in B.A.
Johnson [Ed.], Addiction Medicine. Science and practice. Vol.1 1227-1262 2011

12
Nada Ear acupuncture
in practice
1. Sympathetic 2. Shen men 3. Kidney
4. Liver 5. Lung

1 3

13
 The First Peer Reviewed Report
 China, 1972—Dr. Wen’s anecdotal
observation
• Treating pain in neurosurgical
patients post surgery using
electrostimulation to bilateral ear
Lung points
• Observed patients reporting
amelioration of opiate withdrawal

eEEEEE

14
First NADA “acudetox” Publications
 Shakur, M., and Smith M.O. (1979) The use of
acupuncture n the treatment of drug addiction.
American Journal of Acupuncture, 7(3) 223-228
 Smith, M.O. (1979) Acupuncture and natural healing
in drug detoxification. American Journal of
Acupuncture. 7(2), 97-107
 Group process emphasized

Universal Benefit
 Improvement in engagement and retention
 Relapse prevention
 Reduced alcohol and drug cravings, and
withdrawal symptoms
 Benefit potential is substance and symptom
neutral
 Associated with decrease in positive urine tests,
increased program completion, improved patient
satisfaction, and cost savings
Bullock ML et al, (1989) Controlled Trial of Acupuncture for severe recidivist alcoholism Lancet, 1
(8652) 1435-1439,
Santasiero, RP, Cost-Effectiveness of auricular acupuncture for treating substance abuse in an
HMO setting: A pilot Study. Medical Acupuncture vol.16 no.3 2005

15
 Universal Benefit

- Depression
- Anxiety
- Anger
- Impaired concentration
- Decreased energy
- Body ache / Headaches

Carter, K.O., Olshan-Perlmutter, M., Norton, H.J., & Smith, M.O. (2011) NADA prospective trial in patients with
substance use disorders and seven common health symptoms. Medical Acupuncture (23)3, 139-135

Universal Benefit

 Stress
 Impulsive Behaviors
 Trauma
 Harm reduction
 Individual and Group Psychotherapy
(especially Mindfulness Based Therapies )

Carter K, Olshan-Perlmutter M. (2015) Impulsivity and Stillness: NADA, Pharmaceuticals, and

Psychotherapy in Substance Use and Other DSM 5 Disorders
Stuyt, E.B. Ear acupuncture for co-occurring substance abuse and borderline personality disorder: an aid to
encourage treatment retention .and tobacco cessation. Acupuncture med 2014;32:318-324

16
 Universal Benefit
 NADA may help modify the risks associated with
impulsivity and improve clinical outcomes
 Immediacy of effect makes it especially useful in
acute situations- trauma and medical reserve corps
[MRC]
 Non verbal, does not require learning curve
 Provided in a calm and supportive group setting to
help mitigate impulsiveness
 Balancing experience, general sense of well-being

17
Interpreting conflicting research data
 Impossible to do double blind
 When is a sham really a sham
 NADA as an adjunctive psychosocial tool

NADA Ear Acupuncture: An Adjunctive Therapy to

Improve and Maintain Positive Outcomes in
Substance Abuse Treatment
 Winthrop University/Keystone Substance Abuse Services Center in Rock Hill,
South Carolina
 Objectives –determine if NADA plus traditional treatment is better in
improving and sustaining treatment outcomes including: quality of life and
psychiatric symptoms, maintaining abstinence from drug, alcohol and
tobacco, and decreasing healthcare utilization.
 Design -- Prospective, computer randomized, controlled study; [traditional
Treatment] versus [ traditional Treatment + NADA Protocol]
 Setting -- Keystone Substance Abuse Service 32 week outpatient treatment
setting in Rock Hill, SC
 Participants -- 50 patients in each treatment arm (100 total)

18
Patients Were Randomized to Traditional
Treatment or Traditional Treatment Plus
NADA Protocol

 Traditional group:  NADA group: Patients

received all programs received 5 bilateral ear
offered at KSS IOP acupuncture points
substance abuse (NADA protocol) in a
group setting twice
program which included: weekly throughout there
individual therapy, 12 stay at KSS IOP
Step orientation, and a substance abuse
variety of group therapies program in addition to
traditional treatment

Method
UPON PROGRAM
ADMISSION AND UPON PROGRAM
COMPLETION COMPLETION AND 3 AND
6 MONTH FOLLOW UP
1. Quality of Life and
Satisfaction Questionnaire 1. Patients self-reported
2. PHQ-9 Depression Screening alcohol, tobacco, and
3. GAD-7 General Anxiety drug use
Disorder Screen
4. Drug Screens 2. Healthcare utilization

19
 Nada Protocol Experience
 Treatment administered by a certified/licensed Acupuncture
Detoxification Specialist @ Keystone Substance Abuse Services.
 5 point auricular (ear) acupuncture while seated together in a group
 Needles are inserted at beginning of treatment hour and generally
remain in place for 30-40 minutes.
 Needles are provided in sterile packages, are single use, inserted
once and discarded in designated sharps disposal containers.
 Needles are inserted with brief but steady movement, twirled 180
degrees for smoother insertion.
 Patients may request needle removal at any time during the treatment.
 Acupuncture treatments 2x/week and patients encouraged to attend
all sessions.
 Patients will resume their normal treatment sessions following the
acupuncture session.

Informed Risks
1. You may be randomized to Known side effects
control group and have no Likely
acupuncture for your condition
for 6 months. - Brief ear discomfort
2. It is possible that you receive - Minimal local bleeding upon
acupuncture treatments but do needle removal
not do as well as you have been
doing.
Less Likely
3. Because the treatment is
relatively new, we may not yet - Local bruising
know all the side effects: - Metallic irritation from needle
something unexpected could
happen. - Temporary headache

Rare but Serious

- Vaso-vagal response (fainting)

20
 Results
 Patient characteristics:
 Completion/non-completion differ by race, criminal
history and initial drug test categories.
 Among nonwhites a higher percentage completed the
program in the NADA group.
 Among patients with a positive initial drug test a higher
percentage complete the program in the NADA group.
 Among those with criminal history a higher percentage
failed to complete the program in the control group

21
 Results

Psychological Improvement
 QLES: NADA group show a significant improvement
in quality of life/Q-LES from entry to discharge.
 PHQ-9: Post hoc tests: selected items in the PHQ
(“feeling tired or having energy’ and “feeling bad
about yourself or that you let your family down”)
showed improvement for NADA group
 GAD-7: No statistical difference between groups

22
23
 Maintaining Abstinence
 Both groups improved patients’ ability to maintain
abstinence from alcohol drug and tobacco
consumption between program entry and program
completion.
 Alcohol: NADA group better maintained abstinence
at 3 and 6 months compared to traditional group
 Drugs: No statistical difference
 Tobacco: NADA group better maintained
abstinence at 6 months compared to traditional
group

24
 Additional Results
 Employment: 50% of patients in NADA group and
54.8% patients in control group who completed the
program were unemployed upon entering the
program. At discharge 71% of patients in NADA
group who previously were unemployed had
attained some type of employment vs. 35% of
control group (χ2 =4.01, p<.05).
 Healthcare Utilization: No statistical difference

Janssen PA, Demorest LC, Kelly A, Thiessen P, Abrahams R. (2012)

Auricular acupuncture for chemically dependent pregnant women:
a randomized controlled trial of the NADA protocol.
Subst Abuse Treat Prev Policy, 7:48.

 RCT. Pregnant.
Usual care (n=39) vs NADA added (n=50)
 Outcomes: With NADA, larger reductions in
methadone dose pre-delivery, babies 2 less days of
morphine, shorter duration of neonatal withdrawal
symptoms.
 Problems: only 28% protocol compliance with
NADA.

25
Stuyt EB. (2014). Ear acupuncture for co-occurring substance abuse
and borderline personality disorder: an aid to encourage treatment
retention and tobacco cessation. Acupunct Med., 32:318–324.

 Outcome study-90 day tobacco-free, dual dx

inpatient. NADA voluntary 4x/wk.
 Use of NADA positively correlated w/successful
program completion AND tobacco cessation for
those with BPD.
 Most significant with BPD-- hypothesis, NADA
helped with “distress tolerance”

Bergdahl L, Berman AH, Haglund K. (2014)

Patients’experience of auricular acupuncture during
protracted withdrawal.
J Psych Men Health Nurs.,21:163–169.
 Qualitative study: 15 patients reporting NADA experiences.
- No major AE. Some minor AE: pain w/insertion, time-
consuming.
- Many PE:
• Reduced w/d sx and cravings
• Improved sleep
• Peacefulness
• Increased well-being
• Increased energy
• Decreased physical discomfort
• Decreased irritability

26
 Reilly PM, Buchanan TM, Vafides C, Breakey S, Dykes P. (2014)
Auricular acupuncture to relieve health care workers’
stress and anxiety.
Dimens Crit Care Nurs.,33(3): 151-159

 Mixed methods. Vol/non-randomized. NADA 1x/wk x

16 wks.
 Pop: Healthcare workers on surgical burn/trauma
units
 Methods: pre/post surveys anxiety, burnout &
compassion fatigue.
 Significant reduction in state anxiety, trait anxiety,
burnout and compassion fatigue compared to
baseline.

NADA Protocol and State Laws

 NADA policies vary widely from state to state
 Some states are very restrictive, severely limiting
who may provide and supervise NADA protocol
services.
 NADA availability is accessible with general
supervision requirement
 Direct supervision limits access as it requires a
physician or acupuncturist to be present on site

27
 Animal model of NADA

www.nadauk.com

28
 Opioid-Induced Adverse Effects
OPIOID-INDUCED
HYPERALGESIA
ADDICTION PARADOXICAL PAIN
DRUG SEEKING BEHAVIOR SENSITIZATION
LOCOMOTOR
SENSITIZATION ANALGESIC
TOLERANCE

Animal experiments on acupuncture

treatment for addiction

 Acupuncture treatment can activate GABAB receptors on the

dopamine cell body and presynaptic κ-opioid receptors in the
nucleus accumbens through dynorphin neurons,

 Decreased dopamine release and overall positive

reinforcement

1. Yoon, S. S., Kwon, Y. K., Kim, M. R., et al. (2004) Acupuncture-mediated inhibition of ethanol-induced dopamine
release in the rat nucleus accumbens through the GABAB receptor. Neurosci Lett, 369(3): 234-238. 2. Kiianmaa, K.,
Hyytia, P., Samson

29
 Kailasam VK, Anand P, Melyan Z. (2016)
Establishing an animal model for National Acupuncture
Detoxification Association (NADA) auricular acupuncture protocol.
Neurosci Lett., 624:29–33.
 Animal Study. Morphine-dependent rats.
 NADA vs 5 sham helix. Interdermal 25-30 min x 6 days
 Authors conclusions:
 NADA acupuncture treatment can reduce morphine-
induced locomotor sensitization (indication of craving)
 Prevent the development of morphine tolerance in rats
 Validates NADA for craving reduction
 NADA could be helpful with human opioid chronic pain
management.

Acupressure Seeds and Magnets

 Magnetized metal beads
 Vaccaria seeds
 Can use single point Shen Men or point directly
behind it “reverse Shen Men
 Provides calming effect ,promotes relaxation and
sedation ;regulates and stabilizes emotions
 Noninvasive -more gentle intervention
 More prolonged way to provide stimulation and
support

30
 Benefits
 Administered to neonates/children
 Trauma/Disaster situations
 Preliminary data helpful anxiety/pain/cravings/ADHD
 Noninvasive and easy to administer

Risks
 Local bruising
 Irritation from the hypoallergenic tape
 Temporary scalp discomfort
 Temporary headache
 Ingest 2 or more magnets could cause intestinal
blockage even death
 Keep distance from heart pacemakers
 Allergy to magnets that are nickel plated

31
 Kuo SY, Tsai SH, Chen SL, Tzeng YL.
Auricular acupressure relieves anxiety and fatigue, and reduces cortisol
levels in post-cesarean section women:
a single-blind, randomized controlled study.
Int J Nurs Stud.2016;53:17-26

 RCT Post-cesarean section in hospital care x 5 days

 UC (n=37) vs UC + Shen Men seeds pressure 2x/day (n=39)
 Acupressure sign diff in validated tool self ratings of anxiety
and fatigue; decreased HR, and mean serum cortisol levels.

Tian, X., Kirshnan, S.,

EFFICACY OF AURICULAR ACUPRESSURE AS AN ADJUNCT
THERAPY IN SUBSTANCE TREATMENT: A PILOT STUDY (2006)
vol 12, no. 1

 Placebo controlled single blinded, 6 week trial

UC, UC t acupressure group, UC t placebo control group
 N=6 acupressure group N=6 placebo N=5 UC
 Positive response acupressure group in reducing
emotional distress (Hopkins symptom checklist
depression scale) and cravings Brief substance craving
scale , compared to UC
 Did not distinguish from placebo acupressure group

32
 Best Practices
 Center for Substance Abuse
Treatment. (2006). Center for
substance abuse treatment
detoxification and substance abuse
treatment. TIP series (45) (DHHS
Publication No. [SMA] 06-4131).
Rockville, MD: Substance Abuse and
Mental Health Services.

Best Practices
 2012 Department of Veteran Affairs &
Department of Defense “the evidence is good”
• Post Traumatic Stress Disorder
- Depression
- Anxiety
- Addiction, co-occurring disorders
retrieved from www.healthquality.va.gov/guidelines/MH/ptsd/

33
 Process Improvements and Take Aways
1. NADA protocol is an effective adjunctive treatment for improving outcomes for
patients with substance use disorders as well as co-occurring behavioral health
issues
2. It is easy and safe to use
3. As a non verbal intervention NADA offers a unique opportunity for patient
engagement and retention
4. Permissive regularity statutes minimize treatment barriers for patients, providers
and programs.
5. The standardized NADA training opportunity's and resources are available
nationally and internationally at Acudetox (https://www.acudetox.com/)

Practitioners, Locations & Training

opportunity
 Practitioners—Lay, nurses, SWs, psychologists,
CACs, MDs, acupuncturists, etc.
 Locations—500 US addictions programs using
acupuncture
 Locations--1500 worldwide
Carter K., Olshan-Perlmutter M. (2014) NADA Protocol Integrative Acupuncture
in Addictions. Journal of Addictions Nursing. Vol 25. no. 4, 182-187

34
 STRATEGY for TRIALS
KEEP IT SIMPLE:

(Business as usual)
vs
(Business as usual + NADA)

35
36