18 October 2010

Research on Addiction, Spirituality & Acupuncture

This is a response to a student paper on a research article using acupuncture to treat nicotine withdrawal--

The issue is very timely. Smoking does seem to be on the rise locally, though i've not seen statistics on it.
German research documented the carcinogenic effects of tobacco in 1935, before the chemical additives were used in manufacturing cigarettes. I mention it to patients who feel their smoking is OK, since they smoke 'natural' tobacco. Another point is that the active ingredient is identified in the death process caused by smoking, which knocks 13 years off a life.

Smoking is being promoted by the Chinese government, according to Dr Zwickey of our research department, since it generates revenue.

The problem with numerous studies are manifold. It gets into the heart of the problem with researching addictionology, and how research is missing the spiritual or inner dimension in healthcare.

First, how are patients recruited? This is seldom mentioned. Often though, in conventional trials, an ad is run and patients get paid.

Ever pay anyone to get off alcohol?

Could that ever work?

In acupuncture, the Nei Jing/Inner Classic of acupuncture says healing comes from within. Nowhere is this more clear than treating addictions. When the addict is ready to change, they will endure anything. If they are not ready, nothing changes.

This could be why studies on AA and 12-step programs--our main tool in addictionology--fail in RCTs. If we view a spiritual movement like Recovery as if it were a drug, it doesn't work: Funny!

Ask any worker in the field of addictions if Recovery programs work: They'll ask you, "What else is there?" While not perfect, they are organic, free, widely available, and seem to work. That was my impression, and those of my colleagues in the National Acudetox Association.

Statistics can be illuminating. Prozac got it's start with 5% upticks. 12 and 13 as found in comparing nicotine patches to acupuncture is significant in research. It's not enough for clinicians though.

Government research provided helpful information that most smokers quit on their 5-6th attempt. I tell smokers who fail that it takes multiple attempts (without mentioning a specific number). Some statistics do help us.

It's more the spirit in which they are provided. What we do in acupuncture and addictionolgy is not drug-like. I've yet to see a drug effectively treat chemical dependency. Acupuncture can work better than drugs, in that it has less side effects. But it has an inner aspect that conventional research is not measuring. The reason is that we are often providing an ulterior motive to study participants: cold cash.
The NY Times just had an article on the culture of professional research subjects. There is such a thing. Some make a living doing it.
My experience is that most research projects in Oregon, on the other hand, is with research subjects who possess a great sense of public service for low or no pay.

Qualitative research could assist. Comparing the writing of nicotine patch wearers to acupuncture patients would be something. Combining qualitative with quantitative research is bringing together yin and yang.

Research and all efforts in the field of quitting smoking will help this most difficult process our patients go through, as many of them attest.

15 October 2010

Response to Journalist Query

The excellent question: What is the response of skeptical patients to acupuncture?

In our student clinics, patients are often surprised by the effects. After the first visit, they sometimes wonder whether it was chance, or their imagination, or the Advil they ate many hours ago.

After the second treatment, these doubts clear. 

We welcome skeptics--prefer them to 'true believers,' who are more prone to disappointment if things don't match their expectations. Either way, the effects are noticed.

It takes a skilled practitioner to try different techniques and modalities within the field of acupuncture. About 10-15% of my patients do better with non-needle techniques, such as acupressure or moxa. They are too sensitive for needles, and don't enjoy them as much as these allied modalities. 

When I worked in public health settings, both in and out-patient, we had more than 'skeptics.' There were many patients there for the other public services: not the acupuncture. They would be openly hostile to the process. I found with time ways to reach even the most difficult patient. Often it was a matter of treating a specific pain that would open the door to clinical rapport. Sometimes it was using subtler, less conventional methods such as acupressure or external qigong. 

My finding after several years was that if I had about two weeks with any patient at most, we could find a way to meet their needs using acupuncture-related methods. 

Likewise, the case of the patient undergoing breast reconstruction surgery in Portland in 2004 using acupuncture as the sole means of anesthesia raises questions. This may be beyond what a placebo could reasonably be considered to do. It is also far beyond surprise for both the patient and her healthcare providers. 

11 October 2010

About the Inner Classic

When I went back to acupuncture school for a doctoral program, we were assigned readings from the Inner Classic, our main source text of acupuncture. This 2500 year old book was impenetrable before. My teacher, Dr Li, Yu-tang, asked us simple questions about how a short passage related to our clinical experience.

After struggling with various translations, I found that the one by Wu & Wu was accurate, despite the slightly rough English. To write papers and really get ideas, it was the only one in paperback that made sense. Translations by Tran are excellent and complete in French. They are only now being made into English. They are too expensive for most of my students, but worth it. Henry Lu's new version of the Nei and Nan Jings is exciting and a favorite at my college. However its size and cost puts it out of reach.

For all reliable versions, this roadmap will help. The Nei Jing is seemingly random topics. They may have been intuitively organized at first, but over time the chapter organization was re-created by guesswork. Despite this challenge, the brilliance of this text only grows with age.

The Han dynasty Systematic Classic of Acupuncture/Jia Yi Jing is organized by sections and chapters. There is an excellent translation by Blue Poppy Press that is affordable and clear. However both scholars and students are slow to adopt this book. Some of the ideas are different from the Nei Jing.

Due to the continued popularity of the Nei Jing, this roadmap will help with its biggest problem: the organization.

My hope is that the document of Nei Jing Topics, just posted, will be a kind of open-source software. I encourage others to correct, add to, and distribute this. Please let me know what you find.

When giving classes and talks on acupuncture, people are most excited about this spreadsheet.

Acupuncture is the 'mechanism of action' for Chinese herbs, nutrition, Qigong--all of it. It may lead to a better understanding of homeopathy and all energy medicines. Homeopathy struggles on this very issue: it provides good outcomes in rigorous studies, but the lack of a tenable mechanism limits its current acceptance in some communities. Acupuncture classics also provide the link to the psyche, psychology, soul and internal medicine for many developed manual practices, such as chiropractic and osteopathy. In the latter, very developed and skilled manual methods for manipulating organs have no discussion on what moving an organ means to the mind, psychology or psyche. The acupuncture classics had significant writings on diagnosing organ positions and size, but did not offer treatment. In this age, we can put the two together.

Later writings on Chinese herbs assumed that readers had not just read the Nei Jing, but memorized it --knew it by heart. Herb texts like the Shang Han Lun don't talk much about psychology and the Spirit, perhaps because it was already covered in the Inner Classic.

In TCM programs, it is rare to devote classes to the classics. My teachers in Nanjing were discouraged from spending too much time on it. TCM programs in the US have few, if any classes on these classics. As a result, the doctoral program I was in was surprised by the lack of understanding by practitioners of these texts. We need to start studying them from the beginning, as difficult as it first seems. It is simply a unique language. A text such as by Maciocia can be understood on the first reading, while a translated classic may need three. In college, I found philosphy texts needed six readings for me to start to understand them. The classics were clearer than Hume or Descartes for me. The fact that they are harder than a newspaper seems to dissuade many students.

Knowing classical Chinese is ultimate and necessary. Most of my students will not attain that. We have some students who self-taught themselves Chinese while going through our program. They had enough training from our several teachers with that to take it to completion. Their translations are fearless and unique, in their own voice.

We all need to start somewhere. There are an increasing number of translations in English. Reading them will fire an interest to go further. Not all of us will have the need, interest or capacity for learning classical Chinese. We do what we can. My experience in this field is: you can do a lot with a little.

The Nei Jing is a bold description of the architecture of the soul --Soular Architecture. It can revive medicine's focus on the body as machine. Systems Theory in biology is the other link to rescue us from viewing the body as a mere machine. Between the two, we will see more of the whole picture.

Classical Chinese acupuncture is a gift to the world.

Inner Classic/Nei Jing of Acupuncture: Topics

Wu LW, Wu AQ (trans.).Yellow Emperor's Classic of Internal Medicine. (Wang Bing version) Beijing: China Science & Technology Press. 1997
Annotated notes by Dr. Roger Batchelor (DAOM, LAC) ©10/10/10
Topics in Su Wen/SW & Ling Shu/LS (--pages in parenthesis):
1 Shen SW14, 26-definition (143); LS 32-diet; LS 78
2 Yin-Yang SW 5; LS 40
3 3 Levels SW 20
4 4 Seas LS 33, 36
5 5 Phases SW 50, 51-levels, 69,70, 78
6 6 Stages SW 2,6,16, 21&22-pulses, 31-fever, 35,36, 45, 56, 64, 68-exquisite, 74, 79; LS 72-psych,biotype, 78
7 7 Emotions  (later descriptions after Nei Jing)
8 8 Trigrams / Ba Gua SW 12; LS 77,78
9 9 Pulses SW 20, 27
DX: LS 4
Attitude SW 76, 78; LS 73-perception
Dreams SW17,80 LS 43, 80,
Face SW15, 32, 39, 42; LS 1, 29, 37, 49, 54
Complexion SW13,14,17, 57; LS 10
Forearm SW17, 28; LS 74,75
Pulse: SW10,11,18
Renying-Cunkou SW7; LS 9, 19, 48. [Neck/wrist ratios, later thought to be left/right radial pulses in Pulse Classic/Mai Jing]
5 Phase SW 7,17, 23
Ke cycle SW15
6 Stage SW 21, 22
Death SW 48
Questioning/Sx SW 64, 66; LS 28
Temporality - time sequence SW 36, 39; LS 25
Eye, sclera LS 70, 74, 80
Pediatrics; pregnancy LS 75
DZ: Pain Lumbago-SW 41; LS 26, 53, 71-sites of degeneration
Bi SW 3, 43, 56; LS 6, 13, 27, 46, 49
Diabetes SW 40, 47 (SP D-H); LS 46,47
Heart SW 44; LS 24-attack, 58
Depression LS 22
Mania SW 30, 46, 49,55; LS 22
Headache SW 49; LS 24
Deafness LS 26
Aging, Life Cycles (Development) SW 1, 76, 80-hospice; LS 54
Consumption (exhausion) SW 3,14
Lunar, weather effects SW 26, 63, 69; LS 44, 79
Fever SW 23, LS 31-3, 61
Cough SW 38
Jue SW 45; LS 24
Yin xu SW 62
Ke cycle SW 65, 69
Emotions, Psycho-social SW 8, 21, 24, 39, 67, 77-class, happiness, 79-family roles; LS 5-class, LS 8
Alcohol abuse SW 1, 45-violent(215), 46-hangover; LS 50
Wind LS 49, 58, 77, 79
Edema LS 57
Voice, loss/laryngitis, dysphonia LS 69
Insomnia LS 71, 80
Tumor, cancer LS 81, LS 46 (688)
Pathogen LS 71
Organ size, position- psychology (applications to osteopathy) LS 47 (640)
TX: Plan LS 42-combining; 45-profound
Teaching SW 80; LS 73
Acupuncture: SW 54-9 needles, 61-seasons, contralat-62,63; LS 4-Dao, 60, 77-needles
Skill Levels SW 1
Technique SW16; LS 7-Daoqi, 12-Depth, retention, 67, 73
Clinic SW13; LS 9
Back-shu SW 4, 39; LS 51-moxa
Blood-let SW 24, 35; LS 39
Mental Process SW 25, 26 (143), C2976; LS 73
Neck microsystem SW 32
Contra/caution, prohibitions SW 52-pts.; LS 3, 9, 41, 53-needle phobia, 55, 60,61
Zone tx SW 56
He-pts LS 4, 44
Pediatrics LS 38
TuiNa LS 73
Food SW3; LS 32&37-Shen, 56, 63, 65
Herb SW 23, 75, 37-Ht; LS 71-pinellia/banxia
Attitude, mental health SW 1, 13
Prevention SW 2, 13-psych
Regional influences SW12
Music SW 4; LS 65
Organ: SW9,8-emotion, Position  condition-LS 47, Constitutions-LS 64, Levels-LS 66
HT SW9-primacy; LS 71-Pericardium
SP SW4-spine (25), SW5-formlessness, 29, 47
ST SW5, SW7-larynx,pharynx, 18-Luo, SW 34; LS 68-thought, 80
SJ SW 8, 38; LS 2
Brain SW11-uterus, 81
Uterus SW 11-brain, 33-heart
SI LS 19
Points SW 58, 59, 61-St 36; Sky Windows LS 21
Primary SW 60; LS 2, 5, 16, ST as largest; proportions of Qi/Xue: LS 12
Luo ST Luo-SW 18; SW 34-minor dz, 56, 63; LS 10, 39
Extraordinary: SW 60; LS 17-Qiao
Chong SW 44 (215); LS 38 (664), 64-pathway, 65, 66
Divergent LS 11
Internal LS 10
Sinew / TMM LS 13
Wei [immunology] LS 52, 59-activation pts, 71, 76, 79, 80
Misc. SW 41-lumbago and various special channels

What About Those Studies?

A bright journalist asked me if acupuncture works, considering the studies that find it often doesn't work as well as a toothpick in sham studies. 

Here's one response:

Scientific deliberations take time and care. Research and inquiry functions best when taken across modalities.

Acupuncture is not placebo in that:

  1. Acupuncture works on animals--better than humans: Placebo does not work on animals. There are a quite a few veterinary acupuncturists. I can put you in touch with one, Steve Marsden, if you like. Many are like him: DVMs with secondary degrees in acupuncture, who use this modality extensively in their practice.
  2. There is no such thing as 'sham' acupuncture. There is no real 'control' in acupuncture studies.
    1. Ask any acupuncturist, and they will tell you that all the common shams--toothpicks, fake needles, and sham points--can have significant effects. Some types of acupuncture stimulate the skin without penetration, in effect the toothpick or stage-dagger needle approach.
    2. Likewise, everywhere is a point. We found ear points that the textbook locations led to fast results, while the 'sham' points--only a few millimeters away--simply had slower results noticed by patients: by about 5-10 minutes. I can show you an acupuncture text that includes more points than our beginning textbooks, used with specific purposes, that seem to cover the map. Also, there is experience from Shiatsu that has channels in between the primary ones. This matches patient experiences of pain that sometimes follow these lesser-known pathways (still different from neural ones).
    3. Some control groups are 'wait lists.' This is rarely done, though it matches the reality of chronic care. There are ethical concerns there that limit it as denying healthcare.
    4. Ted Kaptchuk has some articles on PubMed that discuss acupuncture research design and the flaws in conventional controls. However they are pretty dense and wordy articles.
    5. The only real control I've heard of are studies as the VA that apply acupuncture or not during general anesthesia of conventional surgery. However then you are looking at acupuncture in a very unusual circumstance, one which will have limited applications.
    6. Bengston did extensive research that calls into question control groups with energetic interventions, such as acupuncture, homeopathy, and the like. His surprise finding was that if an energetic treatment was applied to rats for cancers, all animals in the building registered an effect. Based on that, we now should go back through all the research to see where the control groups were located relative to one another.
    7. Scientific research on acupuncture is not correlating with clinical reality. Scientists and MDs I mention this to understand it. Conventional RCT research on acupuncture views it as if it were a drug. Instead it is more like surgery, where the issue of controls is also problematic.
  3. Acupuncture and natural medicines are applied holistically, in combination with other therapies. Acupuncture is usually combined with nutrition and lifestyle recommendations, herbs, bodywork, etc. There is a movement to "Whole Systems Research," led by Mikal Aickin, a bio-statistician. This is where treatments are analyzed in whole clinic settings. He sees huge flaws in RCT for natural medicines.
  4. Some see it that we are going about acupuncture research backwards. Hugh MacPherson in the UK came up with this: in drug studies, first we prove the drug is safe, then that it works, and then that it is cost-effective. With acupuncture, looking at safety is done last. Both he and others documented the safety of acupuncture in rigorous reviews. Compare that to aspirin and other drugs. The safety of acupuncture and natural medicines is one of its strongest aspects.
  5. For some conditions, such as chemotherapy-induced nausea, the evidence for acupuncture in RCTs is "overwhelmingly positive," in the view of one MD who now offers it to patients in oncology wards. (It's interesting to me that some of our best outcomes are for this condition, since our main acupuncture classic--the Nei Jing/Inner Classic--focused on the Stomach and digestion as well.)
  6. The research shows that acupuncture doesn't always work, but there are enough rigorous studies that document positive outcomes to say that something is going on here. That intrigues neuro-biologists and others who are focused on the mechanism of acupuncture. One PhD in that field, Richard Hammerschlag, indicates that we are about 2/3 of the way to fully understanding that mechanism. That is enough to inspire some great dialogue across professions that will lead to new discoveries. 
  7. The same meaning applies to patients. Nobody gets excited when Advil works. But if acupuncture works on a patient, they understand themselves, their bodies and their potentials in a new way. Not all of our patients may choose acupuncture, but those that do who find results are teaching others about what is possible. Research at Kaiser that was qualitative found these outcomes in natural medicines: they affected patients' worldviews and sense of self in healthy ways. Pills are not known for this. 
  8. Alternative medicine needs alternative research. Natural medicine will lead to a different research model. Integrative medicine will lead to integrative research --Aickin's Whole Systems Research is leading that. The gap between research and reality needs to be bridged.
  9. Not enough acupuncturists are involved in acupuncture research. Serious practical errors are evident as a result. This makes the treatment interventions flawed to begin with in a striking number of studies.
Bottom line for me:
  • Acupuncture is safe
  • It is cost-effective in both private and public health settings --cheaper than herbs
  • It is highly sought-after by patients
  • There is enough research to "warrant further study," as we say in research-speak, but not enough to be "conclusive."

06 October 2010

What's News?

Yesterday, a group of us from NCNM went to KBOO to tape a show for Sunday morning (830am--you can listen at their webstream at that hour).

We had 4 near-strangers searching for meaning, for 'news,' and this is some of what came up:

Little Portland, Oregon, is the only city on the continent with national-level colleges of every major modality represented: Naturopathic, Chinese Medicine (2), Chiropractic, MD, and Nursing.
This allowed these colleges to collaborate in research comparing outcomes of their respective modalities --nationally funded (through NIH). I participated on a panel that developed acupuncture protocols. These studies take years to make, and the results are still sitting on shelves, waiting to be analyzed and completed. Although the research takes forever, it seems, just getting it off the ground was a boost.

The interviewer, Tom Park, has a great and abiding love for this town. He was excited by the progress in alternative medicine since the 70s, when he first came to Portland and got to know NCNM. It is amazing how far natural therapies have come since when I first started learning them--out of people's homes--in the early 80s. To have real institutions with comparatively vast knowledge and resources at a mind-boggling increase now from then... who could know then it would be this way now?

When we took flower essences and ate brown rice religiously, getting bodywork (--we didn't grow up with that in Ohio) it was with total certainty. We just never guessed it would lead to bricks and mortar, NIH research or real programs. We instinctively knew what we and our friends and patients needed. And we weren't getting it in our families of origin or their doctors --or other institutions, for that matter. Viet Nam changed all of that. I watched my older siblings forge new ways of being, totally cut off from the elders who were drafting them for a war nobody seemed to want. I will never forget what happened at Kent State. Being with Tom, my Elder, reminded me of the power of generational differences. Each one has its most memorable, defining moment.

Portland is ready for a little good news. Homelessness--always growing since the 80s--is more evident: I saw a child sitting on the sidewalk outside the shelter on the Burnside bridge two weeks ago for the first time (the number of homeless families grows and is the least visible aspect of this issue). The Willamette Week--never a Beacon of Hope--this week noted that our county leads the country in illicit drug use.

But one bright light here is medicine: OHSU is our biggest employer. Besides the colleges for the modalities named above (NCNM, Western States Chiropractic, OCOM), there are at least 3 massage schools (Oregon School, East-West, among others), community colleges turning out more LMTs, University of the Pacific with its health programs, and the international Process Work Institute in NW Portland.
Walk around sick in this town, and you are bound to bump into a budding cranial-sacral therapist, homeopathic specialist, or shamanic practitioner (turning out positive outcomes research at Kaiser, no less).

How did this happen? Maybe it was from:
  • The Willamette Valley being termed "the valley of death," according to some urban legends about First People's term for this rich homeland (which I doubt)
  • Enough stubborn flower children getting stuck here in the 70s
  • A lack of pro sports teams to root for
  • The paternalistic healthcare models of timber company towns in the Northwest, leading to relatively more efficient and collective health enterprises in Oregon & Washington
  • Gorgeous beaches and mountains to draw in real healing --and people interested in that

When I lived in Taos, New Mexico, everyone believed in the energy of the land, and that it was most expressed through the dominant mountain. "The mountain decides," was a common refrain. It wasn't just a new age thing. The 'Anglo' population was only one-third.... Whether they were Pueblo Indians, Spanish farmers (first arrived 500 years ago), or retirees from LA, they all spoke the same way on this topic. They saw how recent arrivals were seemingly either welcomed by the land, or shooed away. The land was seen as alive, an independent agent.

Taos Mtn., New Mexico

People's cars starting breaking down in Taos as soon as they invented them in the 1920s, leading to permanent residency for many with no intention of settling in a pin-dot town at 7,000 feet elevation. This led to the establishment of a colony of artists. The painter Georgia O'Keefe, in nearby Abiqiu, was part of that movement:

Red Canna, 1923

As I look at this sometimes-broken, sometimes-healing, always-soulful city named Portland, I wonder how we all got here: Was it Mt. Hood or Tri-met? Some school or the beaches? Where is the energy vortex we owe our draw to? As an acupuncturist, I would like to know the point.

It seems to be growing.