**Yoga & Qigong — A Self-reliant Practice for Health of Body & Mind**

Ping-chung Leung

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Additional information is available at the end of the chapter

http://dx.doi.org/10.5772/60568

#### **Abstract**

Yoga originated from India and is becoming popular worldwide. Qigong originated from China and is less known outside China. Interestingly, both Indian Yoga and Chinese Qigong emphasize on three common components in their fundamental practices, viz. (i) stretching of muscles, tendons and ligaments when thousands of proprioceptive receptors which initiate the "gate theory" of neurological control of pain perception are stimulated; (ii) controlled breathing which harmonizes the somatic and autonomic systems of neurological activities; and (iii) the wonderful outcome after such simple voluntary efforts, a state of tranquility of the mind, which could be understood as Meditation. A comprehensive review on the reports on Yoga and Qigong practices affecting the important physiological processes and mental states of the practitioners is completed to provide reliable information about the value of the practices. Result of the review shows that there are sufficient evidences today, after many carefully planned research studies, on the supportive effects of both Yoga and Qigong on not only neuromuscular pathologies but also problems in cardiovas‐ cular, pulmonary and most remarkably, mental health. Yoga and Qigong practices are good for both the body and mind.

**Keywords:** Yoga, Qigong, Body-mind health

## **1. Introduction**

The current concept of Health is not only "a state of complete physical, mental, social and spiritual well-being, and not merely an absence of disease or free from infirmary" as was

© 2015 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

defined by the World Health Organization [1]. With the increasing complexity of the modern society, the stress and pressure encountered by the individual living in affluent communities could be expected [2]. In the extreme situations, total loss of ability to social adaptation could result in institutionalization in asylum related infrastructures. For the less severely affected, depression and mental stress may significantly affect the activities of daily living of the individual. The rising incidence of psychiatric disorders as a disease therefore appears mandatory [3]. Likewise, apparently normal working individuals may actually suffer from periodical depression in response to fluctuating emotional and work pressure. Psychiatrists and general practitioners are encountering more and more such patients [4]. This group of people under mental stresses may sadly develop into varying degrees of anxiety disorders and depression, or may eventually turn psychiatric. Others, who are either capable of self-care or enjoy good family support, could manage to maintain a reasonably balanced mental stability. The ability to maintain such stability is often the result of special efforts ranging from persis‐ tence on bodily exercises, social activities and unique life styles [5, 6].

In this chapter we explore the value of bodily exercises originated in the Orient that require persistent self-practices through which the individual gradually reaches a state of physical and mental stability, esteeming to a higher level of mental serenity which might carry the individ‐ ual away from the drastic stresses being experienced. Yoga from India and Qigong from China are two popular systems of self-performed bodily exercises that help to maintain the Healthy state of the body and mind [7, 8].

## **2. Yoga and Qigong**

The experts in Yoga or Qigong usually belong to special groups of respectable practitioners and tend to strongly believe that only their own unique stereotyped practices would be able give the best results to guarantee good outcomes. Taking a logical objective view, one could carefully scrutinize the broad framework of the systems of practice to identify the essential components that might be common to the different groups which insist on their limited authorities. Since most of the groups are commanding many enthusiastic followers, there must be commonalities within all the groups in spite of the differences.

With this intension in mind one may identify basic common elements of physical activities in Yoga. They are: special physical postures and stretching exercises; special ways of breathing; and deep relaxation which develops into meditation. For the distinguished experienced expert, a great stress on Indian philosophy is also emphasized [7].

Looking at Qigong: special stretching physical activities with some special postures are also adopted; special ways of breathing are equally stressed, which again lead to deep relaxation and meditation. The philosophical background of Qigong practice is linked with Buddhism, Taoism and Confucianism [9].

Using modern physiological knowledge to conceptualize the special components of activity of both Yoga and Qigong one could link those activities to special stimulations related to unique neurophysiologic pathways that are capable of bringing about a harmonious state between the somatic and the autonomic components of the neurological system [7].

defined by the World Health Organization [1]. With the increasing complexity of the modern society, the stress and pressure encountered by the individual living in affluent communities could be expected [2]. In the extreme situations, total loss of ability to social adaptation could result in institutionalization in asylum related infrastructures. For the less severely affected, depression and mental stress may significantly affect the activities of daily living of the individual. The rising incidence of psychiatric disorders as a disease therefore appears mandatory [3]. Likewise, apparently normal working individuals may actually suffer from periodical depression in response to fluctuating emotional and work pressure. Psychiatrists and general practitioners are encountering more and more such patients [4]. This group of people under mental stresses may sadly develop into varying degrees of anxiety disorders and depression, or may eventually turn psychiatric. Others, who are either capable of self-care or enjoy good family support, could manage to maintain a reasonably balanced mental stability. The ability to maintain such stability is often the result of special efforts ranging from persis‐

In this chapter we explore the value of bodily exercises originated in the Orient that require persistent self-practices through which the individual gradually reaches a state of physical and mental stability, esteeming to a higher level of mental serenity which might carry the individ‐ ual away from the drastic stresses being experienced. Yoga from India and Qigong from China are two popular systems of self-performed bodily exercises that help to maintain the Healthy

The experts in Yoga or Qigong usually belong to special groups of respectable practitioners and tend to strongly believe that only their own unique stereotyped practices would be able give the best results to guarantee good outcomes. Taking a logical objective view, one could carefully scrutinize the broad framework of the systems of practice to identify the essential components that might be common to the different groups which insist on their limited authorities. Since most of the groups are commanding many enthusiastic followers, there must

With this intension in mind one may identify basic common elements of physical activities in Yoga. They are: special physical postures and stretching exercises; special ways of breathing; and deep relaxation which develops into meditation. For the distinguished experienced expert,

Looking at Qigong: special stretching physical activities with some special postures are also adopted; special ways of breathing are equally stressed, which again lead to deep relaxation and meditation. The philosophical background of Qigong practice is linked with Buddhism,

Using modern physiological knowledge to conceptualize the special components of activity of both Yoga and Qigong one could link those activities to special stimulations related to

tence on bodily exercises, social activities and unique life styles [5, 6].

be commonalities within all the groups in spite of the differences.

a great stress on Indian philosophy is also emphasized [7].

state of the body and mind [7, 8].

178 Complementary Therapies for the Body, Mind and Soul

**2. Yoga and Qigong**

Taoism and Confucianism [9].

What does stretching do? Stretching produces tension within the muscles, tendons, ligaments and the components around the joints. Stretching with selected postures produces tension on special groups of muscles, tendons, ligaments and joints that are normally more relaxed, under-used or never extensively used. Muscles, tendons, ligaments and joint capsules are provided with heavy distributions of proprioceptive receptors over their origins and inser‐ tions, so as to enable the detection of movements and subsequently, maintain good coordinations for the need of functional balance. When the proprioceptive receptions are stimulated, a concerted message is sent up the spinal cord to the mid-brain where cortical messages are converged. According to Melzack who invented the "Gate Theory", the pro‐ prioceptive message at the mid-brain, will block off unwanted messages coming in from other brain regions, thus producing a "gate" effect against pain perception, and leading towards a balanced summation of neurological messages from various cortical sources. With every intensional stretch, additional proprioceptive messages are sent up. When muscle groups that are not normally active in day to day activities are activated, they send out massive unusual proprioceptive messages to the mid brain, thus initiating neurological activities pertaining to the "Gate Theory" [10]: a mechanism that blocks pain perception and harmonizes the two indifferent somatic and autonomic neurological systems.

**Figure 1.** Excavated document showing varieties of stretching exercises recommended over 2000 years ago in China.

What does controlled breathing do? Controlled breathing creates unusual motor activities within the respiratory cycles which are directed to follow a new pattern of activity. The modified rates, intensities and duration of inspiration and expiration, the different groups of muscles mobilized and involved, together compose a totally novel, unusual system of respiratory motor activities. Neurological messages received through these complex unusual motor activities are new to the higher central nervous system. The control of respiratory function is unique in that either the somatic motor system, which allows voluntary activities, 11 2000 years ago in China.

4 Book Title

**Figure 2. a.** Stretching in Yoga practice 12 **Fig. 2a.** Stretching **b.** Stretching in Qigong Practice in Yoga practice **Fig. 3b.** Stretching in Qigong Practice

or the autonomic (parasympathetic) nervous system, which generates automatic regulatory activities of respiration, could be responsible. Intentional controlled breathing therefore is making use of the somatic motor activity to impose stimulations on the autonomic nervous system, which has wide connections with the internal organs. Intentional controlled breathing therefore opens up new channels of communication between the internal organs which otherwise stay independent of the body's voluntary control. These new channels of commu‐ nication, could explain how Yoga and Qigong practices help to build up a state of physiological harmony through stretching and controlled breathing, and the subsequent feeling of tranquil‐ ity [11, 12].

What does meditation do? No one is free from the somatic stimulations and cognitive, mental activities culminating into worries and mental disturbances. Busy daily activities may be causes of worries and anxiety. Worldly events straightforward or complicated, may also contribute towards sleep disturbances which seriously affect one's quality of life. Spiritual tranquility is very much adored by those affected. Priests, monks and Buddhists might have special means to achieve a special state of spiritual tranquility. What about ordinary people? Practicing Yoga and Qigong might allow individuals to acquire a mental state like the priest or monk. We have to make postulation according to some basic physiological phenomena so as to understand the mechanisms leading to meditation, when the brain is free from worldly concerns and worries.

The two essential activities that both Yoga and Qigong practice are slow repeated joint stretchings and controlled deep breathings. Joint stretchings initiate the "gate theory" which help to control pain perception. What does deep breathing do?

Normally, lung function, like the heart, the guts and endocrine system, are under the control of the autonomic nervous system. The individual does not need to give any instruction or control; the function of those organs would be automatically maintained. However, the respiratory system enjoys a double favour of either controlled or autonomous function. With this special functional ability, forcing the respiratory processes through the voluntary channel should induce special physiological interactions. The forced inspiratory and extended expiratory movements connect the somatic and autonomic systems, which are normally independent from each other. The bridging effect is probably, a harmonizing process resem‐ bling the "gate theory". The "gate" effect removes pain input. The forced respiratory activity removes or harmonizes unfavourable activities in the other autonomic organs. The harmon‐ ized situation would be felt somewhere in the brain reaching a state of tranquility, i.e. a vivid experience of "Meditation". Yoga and Qigong, through the synchronized activities of stretch‐ ing and forced respiratory training, induce a state of meditation, a supreme feeling of tran‐ quility [9, 11, 12].

## **3. Physiological states**

or the autonomic (parasympathetic) nervous system, which generates automatic regulatory activities of respiration, could be responsible. Intentional controlled breathing therefore is making use of the somatic motor activity to impose stimulations on the autonomic nervous system, which has wide connections with the internal organs. Intentional controlled breathing therefore opens up new channels of communication between the internal organs which otherwise stay independent of the body's voluntary control. These new channels of commu‐ nication, could explain how Yoga and Qigong practices help to build up a state of physiological harmony through stretching and controlled breathing, and the subsequent feeling of tranquil‐

**Figure 2. a.** Stretching in Yoga practice 12 **Fig. 2a.** Stretching **b.** Stretching in Qigong Practice in Yoga practice **Fig. 3b.** Stretching in Qigong Practice

(a) (b)

4 Book Title

10 **Fig.1.** Excavated document showing varieties of stretching exercises recommended over

What does meditation do? No one is free from the somatic stimulations and cognitive, mental activities culminating into worries and mental disturbances. Busy daily activities may be causes of worries and anxiety. Worldly events straightforward or complicated, may also contribute towards sleep disturbances which seriously affect one's quality of life. Spiritual tranquility is very much adored by those affected. Priests, monks and Buddhists might have special means to achieve a special state of spiritual tranquility. What about ordinary people? Practicing Yoga and Qigong might allow individuals to acquire a mental state like the priest or monk. We have to make postulation according to some basic physiological phenomena so as to understand the mechanisms leading to meditation, when

The two essential activities that both Yoga and Qigong practice are slow repeated joint stretchings and controlled deep breathings. Joint stretchings initiate the "gate theory" which

Normally, lung function, like the heart, the guts and endocrine system, are under the control of the autonomic nervous system. The individual does not need to give any instruction or control; the function of those organs would be automatically maintained. However, the respiratory system enjoys a double favour of either controlled or autonomous function. With

the brain is free from worldly concerns and worries.

help to control pain perception. What does deep breathing do?

ity [11, 12].

11 2000 years ago in China.

180 Complementary Therapies for the Body, Mind and Soul

Clinical researches in many institutes have gathered evidences on the effects of Yoga and Qigong on different physiological functions. Improvements in the basic parameters of respiratory functions have been demonstrated [13, 14]. Cardiac functions and related hypertension are also found to improve during the exercises and the effects persist afterwards in both Yoga and Qigong [15-17]. Changes in internal secretions i.e. endocrine adjustments are going along simultaneously with both Yoga and Qigong [18, 19]. The practice of both Yoga and Qigong, and their wide popularity are always linked with satisfactions related to improvements of musculoskeletal strength. Moreover, clear indica‐ tions are available that muscle strengthening and pain alleviation could be a pleasant result in musculo-skeletal diseases [20, 21].

## **3.1. Effects of Qigong on separate physiological functions**

## *3.1.1. Qigong and musculoskeletal function*

Many carefully planned studies have been carried out to study Qigong's direct effects on musculoskeletal function. One study was completed at the Beijing Sports University in 2004 on a group of people aged 50 to 70. After giving standard Qigong training, the physical fitness was assessed, compared with the pre-training states. Results showed that leg and hand grip strengths improved while body weight, pelvic girdle and fat thickness etc. did not change [14].

## *3.1.2. Qigong and cardio-respiratory function*

The Beijing Sports University study also looked at the cardio pulmonary functions of the participants. The heart rates declined at all stages of Qigong training while the respiratory function improved towards the end of the training [14].

Another study done at Jiangxi University on 70 people, 61 to 68 years of age, given Qigong for six months, showed a general improvement of heart functions, measured with high resolution ultrasonic tools, manifested as stroke volume (SV), early and late diastolic velocities (VE and VA).

The results are shown in Table 1 indicating better stroke volume (SV) and early diastolic velocity (VE) in the trained group compared with the control group. VE-VA showed even a more convincing improvement [22].


\*p<0.05; \*\*p<0.01 study group compared on before and after training; #p<0.05 study group compared with control group after six months training.

**Table 1.** Cardiac function before and after training [22].

#### *3.1.3. Qigong and serological data*

There is always doubt whether Qigong would affect endocrine functions which could be revealed from serological markers like cytokines and blood sugar. A study done at Beijing Guang-on-Mun Hospital on patients suffering from diabetes showed that after four months' practice not only was the blood sugar level better controlled but the quality of life also improved [23].

Another study done at Talien on patients with high serum triglycerides showed that 60 minutes of Qigong per day for six months, resulted in improvements in all the relevant biological markers [24, 25].

Positive results after Qigong training were also demonstrated among patients with osteopo‐ rosis, reflected in the parameters of bone metabolism, viz. serum alkaline phosphatase and bone mineral density.

#### *3.1.4. Qigong and mental activities*

Psychologists are interested to know the effects of Qigong exercises on mental activities like cognitive abilities, calculation speed, memory, imitations, making sketches and motor reactions. Experts in Jiangxi have directed studies on elderly people and found that the trained group did better than the untrained group [26, 27].

#### **3.2. Effects of** *Tai Chi* **on physiological functions**

#### *3.2.1. Tai Chi and musculoskeletal problems*

*Tai Chi* is the most popular training exercise in the Chinese Communities, particularly among the elderly people. *Tai Chi* may appear to be gentle, dancing, purely relaxing activities. In fact *Tai Chi* demands the same practice of stretching, controlled breathing and meditation. Training and practices give general physiological supports, very much similar to Qigong. *Tai Chi* is particularly indicated for the rehabilitation of back injuries. One impressive study done in Shanxi for 64 patients suffering from work-related spinal degenerations and back pain showed that *Tai Chi* gave very positive benefits at different stages of training [28] (Table 2).


#### **Table 2.** Treatment results in 4, 8, 12 weeks [28]

#### *3.2.2. Tai Chi and balancing*

The results are shown in Table 1 indicating better stroke volume (SV) and early diastolic velocity (VE) in the trained group compared with the control group. VE-VA showed even a

**Before training After six months' training**

**Control Group (n = 31) Study Group (n = 39)**

SV (ml) 57.94 ± 16.01 58.51 ± 16.99 55.72 ± 15.78 67.15 ± 13.67\*\*# VE (cm/s) 65.95 ± 19.95 66.30 ± 19.75 66.50 ± 18.24 75.05 ± 17.66\*\*# VA (cm/s) 84.36 ± 15.12 82.68 ± 14.10 83.02 ± 13.89 83.76 ± 15.21 VE-VA -18.41 ± 23.98 -16.38 ± 24.68 -16.53 ± 25.96 -10.25 ± 23.32\*

\*p<0.05; \*\*p<0.01 study group compared on before and after training; #p<0.05 study group compared with control group

There is always doubt whether Qigong would affect endocrine functions which could be revealed from serological markers like cytokines and blood sugar. A study done at Beijing Guang-on-Mun Hospital on patients suffering from diabetes showed that after four months' practice not only was the blood sugar level better controlled but the quality of life also

Another study done at Talien on patients with high serum triglycerides showed that 60 minutes of Qigong per day for six months, resulted in improvements in all the relevant biological

Positive results after Qigong training were also demonstrated among patients with osteopo‐ rosis, reflected in the parameters of bone metabolism, viz. serum alkaline phosphatase and

Psychologists are interested to know the effects of Qigong exercises on mental activities like cognitive abilities, calculation speed, memory, imitations, making sketches and motor reactions. Experts in Jiangxi have directed studies on elderly people and found that the trained

*Tai Chi* is the most popular training exercise in the Chinese Communities, particularly among the elderly people. *Tai Chi* may appear to be gentle, dancing, purely relaxing activities. In fact

**Before training After six months'**

**training**

more convincing improvement [22].

182 Complementary Therapies for the Body, Mind and Soul

**Table 1.** Cardiac function before and after training [22].

*3.1.3. Qigong and serological data*

after six months training.

improved [23].

markers [24, 25].

bone mineral density.

*3.1.4. Qigong and mental activities*

group did better than the untrained group [26, 27].

**3.2. Effects of** *Tai Chi* **on physiological functions**

*3.2.1. Tai Chi and musculoskeletal problems*

The dynamic dancing movements of *Tai Chi* would naturally be excellent for the training of people who find difficulties maintaining a normal balance. A large scale study covering 421 people practicing *Tai Chi* regularly, comparing with another group not doing exercise showed marked differences in the single leg stance durability.

#### *3.2.3. Tai Chi and cardio-pulmonary function*

Many scientific reports on the benefits given by *Tai Chi* to cardio-pulmonary function are available. A study conducted in Fujian on middle age and elderly people before and after *Tai Chi* training showed that, after one year, cardiac function, stroke volume, stroke index, cardiac output, pulse rate, cardiac oxygen consumption volume and index, all improved [16] (Table 3).

Although the general mediating effects of exercises on hypertension are well recognized, whether aerobic or otherwise, *Tai Chi* might provide the most remarkable results, when practiced together with regular therapeutic treatment [31]. Some studies have also shown that those suffering from milder hypertension are responding better than the severe ones [32, 33].


**Table 3.** Changes in cardiac function [16].

Effects of *Tai Chi* are also shown in anti-oxidant studies. *Tai Chi* practices have been demon‐ strated to bring down tissue and serum anti-oxidants, viz. superoxide dismutase (SOD), glutathione peroxide (GSHPx), catalase (CAT) and malondialdehype (MDA). It was also apparent that the longer the duration of *Tai Chi* practice, the more active were the anti-oxidant effects (Table 4) [34].


**Table 4.** Relationship between different duration of *Tai Chi* practice [34].

## *3.2.4. Tai Chi and endocrine function*

Gross deficiencies of endocrine function lead to well-known pathologies and disease entities. Mild subclinical deficiencies are the causes of declining physical strength and deteriorat‐ ing health status, particularly affecting the elderlies.The declining tendency with aging has been demonstrated in the evaluation of different hormonal levels in the blood, e.g. testosterone, estrogen, luteohormure, follicular stimulating hormone, thyroxine and thyroid stimulating hormone [Table 5]. *Tai Chi* exercises have been shown to alleviate some of the deficiencies [19].


**Table 5.** Differences in serum hormone level [19].

## *3.2.5. Tai Chi and general health*

**Indice 1996 1997 Rate**

PR (min) 76.18 ± 11.73 72.08 ± 9.18\*\* 5.38 SV (ml) 81.14 ± 1.72 84.05 ± 16.86\* 3.59 CO (L/min) 6.10 ± 1.05 6.42 ± 1.20\* 5.29 SI (ml/m2) 53.15 ± 9.51 55.41 ± 7.52\* 4.24 HOI 2629.74 ± 616.08 2517.58 ± 593.45\* 4.27 HOV (ml/min) 43.82 ± 10.27 40.23 ± 6.94\* 8.19

Effects of *Tai Chi* are also shown in anti-oxidant studies. *Tai Chi* practices have been demon‐ strated to bring down tissue and serum anti-oxidants, viz. superoxide dismutase (SOD), glutathione peroxide (GSHPx), catalase (CAT) and malondialdehype (MDA). It was also apparent that the longer the duration of *Tai Chi* practice, the more active were the anti-oxidant

**1-5 years 5-10 years Over 10 years**

Markers n x ± s n x ± s n x ± s

SOD (NU/m l) 37 78.28 ± 15.27 21 99.66 ± 13.16 13 104.1 ± 12.48 GSH-Px (U/m l) 36 58.08 ± 2.88 22 72.21 ± 11.52 13 77.79 ± 8.75 CA T (U/m l) 37 1.78 ± 0.20 21 2.02 ± 0.19 13 2.05 ± 0.14 MDA (nmol/m l) 29 4.54 ± 0.19 10 4.03 ± 0.39 8 3.62 ± 0.17

Gross deficiencies of endocrine function lead to well-known pathologies and disease entities. Mild subclinical deficiencies are the causes of declining physical strength and deteriorat‐ ing health status, particularly affecting the elderlies.The declining tendency with aging has been demonstrated in the evaluation of different hormonal levels in the blood, e.g. testosterone, estrogen, luteohormure, follicular stimulating hormone, thyroxine and thyroid stimulating hormone [Table 5]. *Tai Chi* exercises have been shown to alleviate some of the

*\*p* < 0.05, *\*\* p* < 0.01.

effects (Table 4) [34].

Differences all reaching *p* < 0.05.

deficiencies [19].

*3.2.4. Tai Chi and endocrine function*

**Table 4.** Relationship between different duration of *Tai Chi* practice [34].

**Table 3.** Changes in cardiac function [16].

184 Complementary Therapies for the Body, Mind and Soul

General health could be reflected from the proneness to ailments of infective origin like common cold and/or influenza. Not only elderlies could be the victims but those suspected of being "low-resistant" against infections could be screened for immunologically related markers: the interleukins (IL's) of which IL2 is probably the most important member which controls the survival of T cells, NK cells and B cells. It has been found that six months of *Tai Chi* exercises among a group of women, aged between 55 and 65, boost up the IL2 level significantly [35, 36].

#### *3.2.6. Tai Chi and mental health*

Like Qigong, *Tai Chi* tends to bring up the psychosocial adaptation ability of the practitioner. Using standard mental assessment Indices, tendencies of depression, anxiety and tension questionaires, the effects of *Tai Chi* have been explored. Compared with non *Tai Chi* groups, advantages are well observed on the *Tai Chi* group [37].

#### **3.3. Outlook of Yoga and Qigong practice on mental health**

In the first place, both systems of physical training aim at the attainment of meditation i.e. mental serenity as the terminal stage of the self-disciplined exercises. Reaching the meditation level requires repeated practices and is subjectively felt by the individual. In the past decade Magnetic Resonance Studies carried out in different institutes have demonstrated that functional activities in different regions of the brain could be affected by sustained postures, musculoskeletal stretches and controlled breathings. These observations are early objective indications of the neurological outcome of Yoga and Qigong [38].

With the complexity of Neuroanatomy and Neuro-Physiology, it might take decades to get nearer to the scientific depths of how Yoga or Qigong influences brain functions. At this stage, we only have clinical evidences from different parts of the world, about the clinical values of Yoga and Qigong on the maintenance of mental health, from prevention to treatment of anxiety disorders and depression.

## **3.4. Yoga**

In 2005 a systematic review on the effects of Yoga on anxiety was completed in the University of West-minister, United Kingdom. Eight studies were reviewed. In spite of many inadequa‐ cies in the methodologies, it appeared that many cases of anxiety state benefited from Yoga, although specific recommendations could not be made [38].

The same group reviewed the effects of Yoga for depression in 2005. They analyzed five randomized controlled trials which all reported positive results although the study method‐ ologies were not perfect [39].

A systematic review done in Australia in 2008 on the effectiveness of Yoga and self-help for anxiety disorders found that Yoga was superior to medications like diazepam [40].

Looking through many other reviews of different academic levels, one realizes the general trend of encouraging results, which may be summarized in the Table 6.

Many other solitary reports on the effects of Yoga on the Mental State of people suffering from different degrees of anxiety disorders are available. Exercise training alone has been proven clinically effective in major depression and panic disorders [46]. Yoga should also provide enhancing effects on standard treatments. Since those maintained on anti psychotic medica‐ tions are more vulnerable to obesity, diabetes and heart diseases, Yoga would be particularly indicated [47, 48], especially for those who are not suitable for aerobic exercises.

Since the 1970's, meditation and other stress-reduction techniques are more and more fre‐ quently practised and studied as possible means of treatments for depression and anxiety. The practice of Yoga, which combines exercises with meditation, unfortunately has been underlooked. The Harvard Medical School Health Review reported that in the recent decades an increasing number of Yoga practices revealed that Yoga reduced the unfavourable influences of exaggerated stress responses, hence should be helpful for anxiety and depression, equiva‐ lent to other self-soothing techniques like therapeutic relaxation, meditation and socialization. Yoga also helped through easing respiration and reducing heart rate which were considered indicators of the bodily ability to response to stress [49]. The tolerability to pain was also increased. Another study at Harvard found that after practicing Yoga for three months, the women involved felt improvements in mental states related to stress, depression, anxiety and fatigue feeling. They also felt stronger and better. Quantitatively, there was a 50% improve‐


**Table 6.** Yoga and meditation for stress, anxiety, anxiety disorders mood disorders, sleep disorders and depression.

ment in depression score, 30% improvement in anxiety score and 65% overall well-being. Other psychosomatic complaints of headache, back pain and sleep disorders also resolved better [50].

A review on Yoga would not be qualified without screening reports from India herself. Indeed the majority of research publications on Yoga has been conducted by Indian investigators and published in Indian journals, although there are increasing contributors from US and England, and increasing applications of Yoga are included in the new specialty of mind-body medicine [46]. A study done in Bangalore India in 2000, comparing the antidepressant effects between Yoga, meditation with imipramine, and electro-convulsive therapy for melancholia, showed that significant reductions in the total score rating of depression occurred in all three groups. At week 3, the Yoga group scored higher than the electro-convulsive group but was not different from the medication group. Remission rates at the end of the trial were 93, 73 and 67% in the electro-convulsive, medication and Yoga groups respectively [50].

## **3.5. Qigong**

functional activities in different regions of the brain could be affected by sustained postures, musculoskeletal stretches and controlled breathings. These observations are early objective

With the complexity of Neuroanatomy and Neuro-Physiology, it might take decades to get nearer to the scientific depths of how Yoga or Qigong influences brain functions. At this stage, we only have clinical evidences from different parts of the world, about the clinical values of Yoga and Qigong on the maintenance of mental health, from prevention to treatment of anxiety

In 2005 a systematic review on the effects of Yoga on anxiety was completed in the University of West-minister, United Kingdom. Eight studies were reviewed. In spite of many inadequa‐ cies in the methodologies, it appeared that many cases of anxiety state benefited from Yoga,

The same group reviewed the effects of Yoga for depression in 2005. They analyzed five randomized controlled trials which all reported positive results although the study method‐

A systematic review done in Australia in 2008 on the effectiveness of Yoga and self-help for

Looking through many other reviews of different academic levels, one realizes the general

Many other solitary reports on the effects of Yoga on the Mental State of people suffering from different degrees of anxiety disorders are available. Exercise training alone has been proven clinically effective in major depression and panic disorders [46]. Yoga should also provide enhancing effects on standard treatments. Since those maintained on anti psychotic medica‐ tions are more vulnerable to obesity, diabetes and heart diseases, Yoga would be particularly

Since the 1970's, meditation and other stress-reduction techniques are more and more fre‐ quently practised and studied as possible means of treatments for depression and anxiety. The practice of Yoga, which combines exercises with meditation, unfortunately has been underlooked. The Harvard Medical School Health Review reported that in the recent decades an increasing number of Yoga practices revealed that Yoga reduced the unfavourable influences of exaggerated stress responses, hence should be helpful for anxiety and depression, equiva‐ lent to other self-soothing techniques like therapeutic relaxation, meditation and socialization. Yoga also helped through easing respiration and reducing heart rate which were considered indicators of the bodily ability to response to stress [49]. The tolerability to pain was also increased. Another study at Harvard found that after practicing Yoga for three months, the women involved felt improvements in mental states related to stress, depression, anxiety and fatigue feeling. They also felt stronger and better. Quantitatively, there was a 50% improve‐

anxiety disorders found that Yoga was superior to medications like diazepam [40].

indicated [47, 48], especially for those who are not suitable for aerobic exercises.

trend of encouraging results, which may be summarized in the Table 6.

indications of the neurological outcome of Yoga and Qigong [38].

although specific recommendations could not be made [38].

disorders and depression.

186 Complementary Therapies for the Body, Mind and Soul

ologies were not perfect [39].

**3.4. Yoga**

As stated earlier, Qigong is composed mainly of three essential self-attained activities, viz., stretching across joints, controlled breathing and meditation. Which mechanisms are most important towards the accomplishments of a physiological harmony presenting as both physical and mental well-being? Many theories have been postulated. One theory emphasizes on muscle relaxation, claiming that relaxation brings about improved blood circulation, better oxygen provision and removal of metabolic wastes. Another theory and limited experiments have shown the enhancement of the immunological defense. It is observed that relaxation, and controlled breathing could be giving the mind an effective training to relieve stress and pain. Other scientists have demonstrated changing hormonal levels in the blood during Qigong practice, while at the same time suppressing sympathetic output [51, 52].

With regard to research publications on Qigong, plentiful are available in Chinese language journals but the methodologies of studies are largely of low quality. The reports are mostly from sports related studies and analyses tend to be superficial.

A report from Wuhan, China, on the elderlies practicing Qigong showed that 6 weeks' practice reduced anxiety and depression primarily felt by the individuals while cardiac and pulmonary functions also improved [51]. Another study completed in Shanxi in 2005 approached from the ancient Chinese philosophers' context, but whether Confucian or Taoist philosophical views are suitable for the interpretation of harmonizing observations remain controversial [52].

A controlled study was done in 2006 on 600 people practicing and not practicing Qigong. Those who had long experience were found to have more stable mental health [53].

A group of hospital workers in USA were given Qigong training for six weeks after which they were assessed using the Perceived Stress Scale together with the quality of life, questionnaire, using the SF36 questionnaire. The outcome was compared with another group of hospital workers not trained. The Qigong group demonstrated statistically significant reduction of perceived stress compared to the control group (p=0.02) Greater improvement on the quality of life was also found in the Qigong group [54].

Medical Students who practiced Qigong for 12 weeks were studied on their mental adapta‐ bility: including depression, anxiety, aggressiveness, threat, stubbornness and social behav‐ iors. 100 of them were compared with 50 others who did not practice Qigong. The practicing group showed significantly higher scores (p<0.01) [55].

A detailed case study done in Sweden on the mood recovery of a woman who lost her job and became dreadfully distressed was most interesting. After practicing Qigong, the woman was found to continuously benefit from the exercises. Exercise behaviour was recorded daily, stress-energy and wellness were followed up weekly and mindfulness after 4, 9 and 12 weeks. The woman felt that her mental state was enjoying progressive stabilisation to high levels: she could better adapt to stressful situations and was less worried about unexpected mishappen‐ ings in life [56]. She believed firmly that Qigong was the main cause of her achievements.

Reports about mental health after Yoga and Qigong training on the whole, are giving rather vague ideas of the state of the mind. "Stable mental health" is often stated. To the experts on mental health, it means little because specific psychiatric symptoms are not described.

## **4. Conclusion**

physical and mental well-being? Many theories have been postulated. One theory emphasizes on muscle relaxation, claiming that relaxation brings about improved blood circulation, better oxygen provision and removal of metabolic wastes. Another theory and limited experiments have shown the enhancement of the immunological defense. It is observed that relaxation, and controlled breathing could be giving the mind an effective training to relieve stress and pain. Other scientists have demonstrated changing hormonal levels in the blood during Qigong

With regard to research publications on Qigong, plentiful are available in Chinese language journals but the methodologies of studies are largely of low quality. The reports are mostly

A report from Wuhan, China, on the elderlies practicing Qigong showed that 6 weeks' practice reduced anxiety and depression primarily felt by the individuals while cardiac and pulmonary functions also improved [51]. Another study completed in Shanxi in 2005 approached from the ancient Chinese philosophers' context, but whether Confucian or Taoist philosophical views are suitable for the interpretation of harmonizing observations remain controversial [52].

A controlled study was done in 2006 on 600 people practicing and not practicing Qigong. Those

A group of hospital workers in USA were given Qigong training for six weeks after which they were assessed using the Perceived Stress Scale together with the quality of life, questionnaire, using the SF36 questionnaire. The outcome was compared with another group of hospital workers not trained. The Qigong group demonstrated statistically significant reduction of perceived stress compared to the control group (p=0.02) Greater improvement on the quality

Medical Students who practiced Qigong for 12 weeks were studied on their mental adapta‐ bility: including depression, anxiety, aggressiveness, threat, stubbornness and social behav‐ iors. 100 of them were compared with 50 others who did not practice Qigong. The practicing

A detailed case study done in Sweden on the mood recovery of a woman who lost her job and became dreadfully distressed was most interesting. After practicing Qigong, the woman was found to continuously benefit from the exercises. Exercise behaviour was recorded daily, stress-energy and wellness were followed up weekly and mindfulness after 4, 9 and 12 weeks. The woman felt that her mental state was enjoying progressive stabilisation to high levels: she could better adapt to stressful situations and was less worried about unexpected mishappen‐ ings in life [56]. She believed firmly that Qigong was the main cause of her achievements.

Reports about mental health after Yoga and Qigong training on the whole, are giving rather vague ideas of the state of the mind. "Stable mental health" is often stated. To the experts on mental health, it means little because specific psychiatric symptoms are not described.

who had long experience were found to have more stable mental health [53].

practice, while at the same time suppressing sympathetic output [51, 52].

from sports related studies and analyses tend to be superficial.

188 Complementary Therapies for the Body, Mind and Soul

of life was also found in the Qigong group [54].

group showed significantly higher scores (p<0.01) [55].

Exercises have long been known to be good and effective means of self-administered treatment, not only for physical strengthening but also in attempts to sooth the mind. Indeed, many past and current studies have given good evidences to the objective reasoning and physiological changes behind the simple practice. Practicing meditations under various artificial initiations, have attracted a lot of attention as an effective means of promoting mental health.

When Yoga and Qigong both require sustained stretching and controlled breathing, leading gradually into a state of meditation, the self-initiating activities could be triggering off combined or synergistic effects derived from different levels of neurological activities. Harvard University has conducted a survey on Yoga practitioners in 2008, and found that they were mainly people (woman more than men) who were suffering from musculoskeletal or mental disturbances. The survey indicated that 5.1% of US populations have used Yoga for health in the last 12 months, representing 10.4 million individuals. The data gives sufficient support for further recommendation on the popular use of the simple safe practice, so easily learned and adopted by all [57]. When Mayo Clinic staff made wide papaganda on exercises, using this slogan: "Depression and Anxiety: Exercises ease Symptoms" and giving clear explanations and instruction on Yoga, they were well accepted [58].

Given the great similarities between Yoga and Qigong, there might be a great justification for exploring the two systems of therapies together, when they are recommended as alternative treatments for a holistic body-mind resolution against health deterioration, declining physi‐ que, stress, anxiety and depression. Yoga or Qigong is a safe prescription for healthy living and provides a rich ground for harmonized human existence basing on the mind's selfregulatory processes against mental stresses. The two alternative therapies may control mental health disruptions like anxiety and depression, helping to maintain an ideal quality of life [59].

The author is neither an expert on Yoga nor Qigong. He is a clinician researching on Alternative Medicine as a supplementary support to mainline scientific allopathic medicine. He does practice Qigong and has studied Yoga superficially. He realizes Yoga and Qigong could both be excellent additional support for physical and mental health. While searching for literal evidences to illustrate the value of Yoga and Qigong for mental health, he found many convincing conceptual literature, superficial in the scientific sense, but well covers the breadth that is required for those interested to know more about Yoga and Qigong. Readers need not be disappointed with the lack of specific evidences on specific mental diseases, because Yoga and Qigong are meant to be supplementary, not replacing the conventional specialist treat‐ ment. Likewise, strict scientific data like hormones and transmitters might have been included in some of the reports, but however, for the general proof of concept, being too specific might lead to a different direction of treatment specific application which should not be encouraged.

For those interested to develop alternative medicine, some prefers moving towards specific focci of their major concern. As far as the author is concerned, he is more capable of simply taking a general approach with the sincere wish of bringing more medical workers to the awareness of the importances of supplementary role of alternative medicine.

The World Health Organization, in its deliberations on Traditional Medicine Strategy, is emphasizing the importance of "Self-care Health" as a most practical way of improving global health [60]. Yoga and Qigong are effective traditional means of self-practice, not only for the musculo-skeletal aspects, as could be readily seen, but also for the mind.

## **Author details**

Ping-chung Leung1,2

1 Professor Emeritus, Orthopaedics & Traumatology, The Chinese University of Hong Kong, Shatin, Hong Kong, China

2 State Key Laboratory of Phytochemistry and Plant Resources in West China, The Chinese University of Hong Kong, Shatin, Hong Kong, China

## **References**


[9] Leung PC. Natural Healing in Chinese Medicine: Qigong and Tai Chi. In: Leung PC, editor. Healthy Aging. Singapore: World Scientific Publishing; 2011.

The World Health Organization, in its deliberations on Traditional Medicine Strategy, is emphasizing the importance of "Self-care Health" as a most practical way of improving global health [60]. Yoga and Qigong are effective traditional means of self-practice, not only for the

1 Professor Emeritus, Orthopaedics & Traumatology, The Chinese University of Hong

2 State Key Laboratory of Phytochemistry and Plant Resources in West China, The Chinese

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## **Role of Acupuncture in the Treatment of Drug Addiction**

Anfeng Xiang, Boyuan Zhang and Sheng Liu

Additional information is available at the end of the chapter

http://dx.doi.org/10.5772/60655

#### **Abstract**

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abstract

s21201en/s21201en.pdf

This review systematically assessed the clinical evidence for and against acupuncture as a treatment for drug addiction. The existing scientific rationale and possible mechanisms for the effectiveness of acupuncture on drug addiction were also evaluated. We used computerized literature searches in English and Chinese and examined texts written before these computerized databases existed. We also used search terms of treatment and neurobiology for drug abuse and dependence. Acupuncture showed evidence for relevant neurobiological mechanisms in the treatment of drug addiction. Although positive findings regarding the use of acupuncture to treat drug dependence have been reported by many clinical studies, the data do not allow us to make conclusions that acupuncture was an effective treatment for drug addiction, given that many studies reviewed here were hampered by small numbers of patients, insufficient reporting of randomization and allocation concealment methods, and strength of the inference. However, considering the potential of acupuncture demonstrated in the included studies, further rigorous randomized controlled trials with long follow-up are warranted.

**Keywords:** acupuncture, addiction, heroin, cocaine, treatment

## **1. Introduction**

Acupuncture originated in ancient China and has been used to manage various clinical disorders for thousands of years in China. Acupuncture needles insert into acupuncture points of the body to treat many different disorders. Acupuncture needles are manipulated manually. One of the recent technical developments was to use peripheral electrical stimulation applied

© 2015 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

via the acupuncture needles inserted into the acupoints, that is, "electroacupuncture" (EA). Currently, new methods for stimulating the acupuncture points include applying electric current to skin electrodes over the points, directing a laser light onto the points, or using finger pressure to massage selected points (acupressure). In addition, many new points and entire "microsystems" of points have been described for specific body parts, for example, scalp acupuncture and ear acupuncture (auricular acupuncture). In Western countries, acupuncture began to be known in the middle of the 1970s, yet its acceptance has increased rapidly. Many Western patients turn to acupuncture along with conventional medical therapy to make sure they are utilizing all possible medical options. A recent survey of acupuncture released by an NIH Consensus Development Panel indicated that although there are inherent problems of design, sample amount, and appropriate controls in the acupuncture literature, extensive work has shown that acupuncture is beneficial in treating various pain syndromes, postoperative and chemotherapy- induced nausea and vomiting, some forms of bronchial asthma, headache, migraine, and female infertility. For the past 40 years, a number of studies of acupuncture applied, as a medical technique, to the treatment of heroin, alcohol, nicotine, and cocaine addictions have been reported. In light of an increasing trend in the use of acupuncture and utilization of such approaches by patients suffering from drug addiction, we intend to review the existing scientific rationale and clinical data, which indicate that acupuncture may influence the prognosis of drug addicts.

## **2. Acupuncture: Theory and mechanisms**

It has long been a dream to cure diseases by nonpharmacological measures that activate selfhealing mechanisms, without using drugs. Recent efforts along these lines were the use of vagal nerve stimulation, repetitive transcranial magnetic stimulation (rTMS), deep brain stimulation, and acupuncture to stimulate certain brain areas. Evidence presented in the present review demonstrates that it is possible to facilitate the release of certain neuropeptides in the central nervous system (CNS) by means of peripheral acupuncture point's stimulation. In contrast to magnetic stimulation that stimulates the superficial areas of the brain (i.e., the cortex) [1], acupuncture activates various brain structures and/or the spinal cord via specific neural pathways. Any predictions made at this stage should not be overly optimistic. But the clinical efficacy demonstrated using acupuncture to ease postoperative pain [2,3], lower-back pain [4,5], and diabetic neuropathic pain [6], and the successful application of 100 Hz (but not 2 Hz) electroacupuncture for treating muscle spastic pain of spinal origin [7]E certainly hold exciting promise for the future. Gaining knowledge of therapeutic mechanisms is essential to validating therapies such as acupuncture that are difficult to test under double-blind, placebocontrolled conditions. If we try to answer the question "how the acupuncture works or what physical changes occur", it is appropriate first to give some theoretical background for acupuncture. Clinical treatment with acupuncture is done in light of symptom differentiation and therapeutic methods, by means of needling and moxibustion (lighted punks of *artemis vulgaris*) with certain manipulating methods to stimulate the selected acupuncture points for prevention and treatment of diseases. The theory of meridians and acupuncture points is the basic theory of therapy. In fact, traditional Chinese medicine is based on the concept of the flow of energy or Qi through meridian pathways in the body. Qi is postulated to flow through the body in precisely located pathways or channels called meridians. These meridians are thought to be connected to various body organs as well as to each other. According to the principles of traditional Chinese medicine, illness results from an imbalance of energy flow within these meridians. Acupuncture was developed according to the principle that human bodily functions are controlled by the "meridian" and "Qi" systems. There are 365 designated acupuncture points located along these meridians. Acupuncture stimulates the points located on "meridians" along which Qi flows, breaking the blockage, and subsequently restoring the flow of energy and healthy body functioning [8].

via the acupuncture needles inserted into the acupoints, that is, "electroacupuncture" (EA). Currently, new methods for stimulating the acupuncture points include applying electric current to skin electrodes over the points, directing a laser light onto the points, or using finger pressure to massage selected points (acupressure). In addition, many new points and entire "microsystems" of points have been described for specific body parts, for example, scalp acupuncture and ear acupuncture (auricular acupuncture). In Western countries, acupuncture began to be known in the middle of the 1970s, yet its acceptance has increased rapidly. Many Western patients turn to acupuncture along with conventional medical therapy to make sure they are utilizing all possible medical options. A recent survey of acupuncture released by an NIH Consensus Development Panel indicated that although there are inherent problems of design, sample amount, and appropriate controls in the acupuncture literature, extensive work has shown that acupuncture is beneficial in treating various pain syndromes, postoperative and chemotherapy- induced nausea and vomiting, some forms of bronchial asthma, headache, migraine, and female infertility. For the past 40 years, a number of studies of acupuncture applied, as a medical technique, to the treatment of heroin, alcohol, nicotine, and cocaine addictions have been reported. In light of an increasing trend in the use of acupuncture and utilization of such approaches by patients suffering from drug addiction, we intend to review the existing scientific rationale and clinical data, which indicate that acupuncture may

It has long been a dream to cure diseases by nonpharmacological measures that activate selfhealing mechanisms, without using drugs. Recent efforts along these lines were the use of vagal nerve stimulation, repetitive transcranial magnetic stimulation (rTMS), deep brain stimulation, and acupuncture to stimulate certain brain areas. Evidence presented in the present review demonstrates that it is possible to facilitate the release of certain neuropeptides in the central nervous system (CNS) by means of peripheral acupuncture point's stimulation. In contrast to magnetic stimulation that stimulates the superficial areas of the brain (i.e., the cortex) [1], acupuncture activates various brain structures and/or the spinal cord via specific neural pathways. Any predictions made at this stage should not be overly optimistic. But the clinical efficacy demonstrated using acupuncture to ease postoperative pain [2,3], lower-back pain [4,5], and diabetic neuropathic pain [6], and the successful application of 100 Hz (but not 2 Hz) electroacupuncture for treating muscle spastic pain of spinal origin [7]E certainly hold exciting promise for the future. Gaining knowledge of therapeutic mechanisms is essential to validating therapies such as acupuncture that are difficult to test under double-blind, placebocontrolled conditions. If we try to answer the question "how the acupuncture works or what physical changes occur", it is appropriate first to give some theoretical background for acupuncture. Clinical treatment with acupuncture is done in light of symptom differentiation and therapeutic methods, by means of needling and moxibustion (lighted punks of *artemis vulgaris*) with certain manipulating methods to stimulate the selected acupuncture points for prevention and treatment of diseases. The theory of meridians and acupuncture points is the basic theory of therapy. In fact, traditional Chinese medicine is based on the concept of the flow of energy or Qi through meridian pathways in the body. Qi is postulated to flow through

influence the prognosis of drug addicts.

196 Complementary Therapies for the Body, Mind and Soul

**2. Acupuncture: Theory and mechanisms**

Acupuncture points on the body have both local and systemic influences. Pain, for example, is treated not only locally but distally as well, via acupuncture points further along the meridian, drawing energy away from the pain. Conditions caused by organ dysfunction such as asthma or drug addiction are differentiated according to the specific symptoms present. Acupuncture points are then selected appropriate to both the symptoms reported and the cause of that individual's problems.

Although different direction, angle and depth for inserting needles, stimulation intensity, such as rolling, raising, and thrusting, and Deqi may have an effect through different actions, the condition of the patient is the most important factor that influences the effectiveness of acupuncture. Numerous examples reveal that the regulatory effect of acupuncture has the characteristics of holism and bidirectional regulation. In acupuncture theory, bidirectional regulation is referred to a balancing effect of acupuncture interventions when the human body is experiencing a hyperactivity or hypoactivity due to abnormal intrinsic or external factors. The same acupuncture points' stimulation with different manipulating techniques or stimu‐ lation parameters can regulate different functional activities of the body bidirectionally, which means to balance the functions of the body when they become hyperactive with the inhibiting effect and to restore the normal functions of the body when they become hypoactive with the exciting effect. For example, when blood pressure is too high, needling Neiguan (PC.6) can reduce high blood pressure; when blood pressure is too low, needling PC.6 can elevate blood pressure. Acupuncture-induced correction of abnormal blood pressure is observed to be dependent on the nervous, endocrinal, humoral, and dielectric regulation. Take Zusanli (ST. 36) for another example, EA at Zusanli (ST.36) can biregulate gastric activity. For gastric hypermotility, EA at ST.36 can inhibit gastric movement; but for bradygastria, EA at ST.36 can promote the peristalsis of the stomach. In addition, it is notable that some of the acupuncture points can bear special or specific curative effect on certain diseases. For example, Dazhui (GV. 14) abates fever and Zhiyin (BL.67) rectifies the position of fetus [9].

The guidance of the theory of traditional Chinese medicine is traditionally believed to be essential in achieving acupuncture's therapeutic effect, but the metaphysical explanations may be hard to understand by modern science. In recent years, increasing research publications gave strong evidence that acupuncture could be explained on a physiological and neurobio‐ logical rather than a metaphysical basis [10, 11]. For example, in traditional Chinese medicine, the vision-related acupuncture point (VA1) (known as urinary bladder channel of BL67) is believed to be an effective acupuncture point that directly treats eye-related disorders. Various acupoints are related to corresponding specific organs rather than via the central nervous system. Based on the knowledge of Western medicine, it is difficult to believe that acupuncture treats disorders and diseases by direct control of organs or organ-related disorders and diseases. It is known that many disorders are either controlled or affected by the brain, i.e., specific corresponding brain functional areas. Recently, Cho et al. [12] demonstrated that when acupuncture stimulation is performed at VA1 (vision-related acupuncture point), activation of occipital lobes is seen by functional magnetic resonance imaging (fMRI). Stimulation of the eye by directly using light evokes similar activation in the occipital lobes. It may represent an important step toward understanding oriental acupuncture in relationship to brain function. In addition, the findings by Bruce Rosen of Harvard Medical School at the American Psycho‐ somatic Society Meeting in Orlando showed that acupuncture on pain-relief points cut blood flow to key areas of the brain related with pain within seconds. Researchers applied acupunc‐ ture needles to acupuncture points on the hand linked to pain relief in traditional Chinese medicine. Blood flow decreased in certain areas of the brain, which was detected by fMRI within seconds of volunteers reporting a sense of heaviness in their hands, a sign that the acupuncture is working. The needling technique is not supposed to hurt if done correctly. When a few subjects reported pain, the fMRI scannings showed an increase of blood to the same brain areas. It may provide a clear explanation to date for how the ancient acupuncture might relieve pain.

Recently, the neurophysiology of acupuncture has been investigated extensively and reviewed in detail. The principal suggestion is that acupuncture operates largely through neurotrans‐ mitters, particularly endorphin-related mechanisms. These studies demonstrate conclusively that acupuncture's effects are related to the release of a variety of neurotransmitters including natural opiates and, furthermore, that this effect is naloxone-reversible. Basic research work carried out has demonstrated that any noxious stimulus will result in endorphin release through the neurophysiological mechanism described as diffuse noxious inhibitory control (DNIC). Therefore, DNIC represents a nonspecific physiological mechanism which triggers the natural opiate system in both man and experimental animal. It has been suggested that DNIC plays a relatively minor role in acupuncture analgesia and that other systems, mediated by serotonin and noradrenaline, may be important. The mechanism of acupuncture in internal diseases, such as asthma, irritable bowel, and the treatment of symptoms such as nausea is completely unknown. Acupuncturists have hypothesized that the autonomic nervous system plays an important, but not as yet ill-defined, part in the underlying mechanisms that are involved in the treatment of such internal problems.

## **3. Effects of acupuncture on drug dependence**

Conventional detoxification methods such as methadone and buprenorphine are effective in reducing illicit opioid use, but problems associated with their use, such as social resistance to the idea of "replacing one drug of abuse with another"and difficulties in tapering patients off the medication due to long-lasting withdrawal effects, make the search for alternative therapies important [13].

Acupuncture's utility for treating drug abuse and dependence is best shown in opioiddependent patients experiencing withdrawal [14, 15]. Over the past 40 years, acupuncture and EA have been applied with great success to attenuate behavioral signs of opioid withdrawal in addicts [16-18]. Using acupuncture to treat drug withdrawal symptoms began in 1972. H. L. Wen, a neurosurgeon from Hong Kong, visited China to learn acupuncture anesthesia. Upon returning to his Hong Kong practice, he used electrical stimulation via acupuncture needles to reduce or eliminate the need for anesthetic drugs during surgery. Acupuncture treatment was given over several weeks prior to surgery, as well as during operational procedures. Dr. Wen was unaware that some patients were also heroin, opium, morphine, alcohol, and/or nicotine dependent. The addict patients later volunteered this information, and reported that they also lost their drug cravings after receiving acupuncture. Wen and his colleagues followed up 40 patients for opium and heroin addiction. They confirmed that 39 of 40 patients were considered improved in that they had gained basal weight and reported they did not crave drugs [19-21]. In the United States, Smith and coworkers [22-25] modified Wen's original protocol by eliminating electrical stimulation and by using an abbreviated prescription of fivepoint auricular acupuncture. This prescription was not designed for withdrawal from any class of drug or any single abused substance. Instead, it effectively reduced cravings, anxiety, and dysphoria of withdrawal in addict patients during withdrawal from a variety of drugs and alcohol. Patients consistently reported the dramatic relief during the early weeks of with‐ drawal, when the incidence of relapse is highest. By 1974, Smith had used this five-point auricular protocol as the sole detoxification method used in the outpatient clinic at Lincoln Hospital in the Bronx, NY. Over the past 40 years, this acupuncture protocol has grown in popularity. It is currently used to treat alcohol and other drug withdrawal in more than 800 substance abuse treatment centers across the United States and Europe.

treats disorders and diseases by direct control of organs or organ-related disorders and diseases. It is known that many disorders are either controlled or affected by the brain, i.e., specific corresponding brain functional areas. Recently, Cho et al. [12] demonstrated that when acupuncture stimulation is performed at VA1 (vision-related acupuncture point), activation of occipital lobes is seen by functional magnetic resonance imaging (fMRI). Stimulation of the eye by directly using light evokes similar activation in the occipital lobes. It may represent an important step toward understanding oriental acupuncture in relationship to brain function. In addition, the findings by Bruce Rosen of Harvard Medical School at the American Psycho‐ somatic Society Meeting in Orlando showed that acupuncture on pain-relief points cut blood flow to key areas of the brain related with pain within seconds. Researchers applied acupunc‐ ture needles to acupuncture points on the hand linked to pain relief in traditional Chinese medicine. Blood flow decreased in certain areas of the brain, which was detected by fMRI within seconds of volunteers reporting a sense of heaviness in their hands, a sign that the acupuncture is working. The needling technique is not supposed to hurt if done correctly. When a few subjects reported pain, the fMRI scannings showed an increase of blood to the same brain areas. It may provide a clear explanation to date for how the ancient acupuncture

Recently, the neurophysiology of acupuncture has been investigated extensively and reviewed in detail. The principal suggestion is that acupuncture operates largely through neurotrans‐ mitters, particularly endorphin-related mechanisms. These studies demonstrate conclusively that acupuncture's effects are related to the release of a variety of neurotransmitters including natural opiates and, furthermore, that this effect is naloxone-reversible. Basic research work carried out has demonstrated that any noxious stimulus will result in endorphin release through the neurophysiological mechanism described as diffuse noxious inhibitory control (DNIC). Therefore, DNIC represents a nonspecific physiological mechanism which triggers the natural opiate system in both man and experimental animal. It has been suggested that DNIC plays a relatively minor role in acupuncture analgesia and that other systems, mediated by serotonin and noradrenaline, may be important. The mechanism of acupuncture in internal diseases, such as asthma, irritable bowel, and the treatment of symptoms such as nausea is completely unknown. Acupuncturists have hypothesized that the autonomic nervous system plays an important, but not as yet ill-defined, part in the underlying mechanisms that are

Conventional detoxification methods such as methadone and buprenorphine are effective in reducing illicit opioid use, but problems associated with their use, such as social resistance to the idea of "replacing one drug of abuse with another"and difficulties in tapering patients off the medication due to long-lasting withdrawal effects, make the search for alternative therapies

Acupuncture's utility for treating drug abuse and dependence is best shown in opioiddependent patients experiencing withdrawal [14, 15]. Over the past 40 years, acupuncture and

might relieve pain.

198 Complementary Therapies for the Body, Mind and Soul

important [13].

involved in the treatment of such internal problems.

**3. Effects of acupuncture on drug dependence**

Clinical studies and related research on acupuncture have been undertaken by independent groups. Some randomized trials have been done to compare the effects of auricular acupunc‐ ture at specific points for the treatment of substance abuse and at sham points [26-28]. Washburn et al. [29] conducted the first controlled study of acupuncture heroin detoxification. One hundred addicted persons were randomly assigned, in a single-blind design, to the standard auricular acupuncture treatment used for addiction or to a "sham" treatment that used points that were geographically close to the standard points. They observed that subjects assigned to the standard treatment attended the acupuncture clinic more days and stayed in treatment longer than those assigned to the sham condition. Zhang et al. [26] also found that acupuncture and electrical stimulation were more effective than clonidine in treating with‐ drawal syndromes such as insomnia, pain, and anxiety following acute withdrawal symptoms. Clinical studies have also demonstrated that this treatment has fewer side effects. In addition, Meade et al. [30] tested the effectiveness of transcutaneous electric acupoint stimulation (TEAS) as an adjunctive treatment for inpatients receiving opioid detoxification with buprenorphine– naloxone at a private psychiatric hospital. It is shown that TEAS is an acceptable, inexpensive adjunctive treatment that is feasible to implement on an inpatient unit and may be a beneficial adjunct to pharmacological treatments for opioid detoxification. Acupuncture also appears to be a useful adjunct to methadone maintenance therapy (MMT) in heroin addiction. Recently, one study examined the effectiveness of acupuncture for heroin addicts on methadone maintenance by measuring the daily consumption of methadone, variations in the 36-item Short Form Health Survey-36 (SF-36) and Pittsburgh Sleep Quality Index (PSQI) scores. It is shown that acupuncture was also associated with a greater improvement in sleep latency at follow-up. All adverse events were mild in severity [31].

A number of studies have examined the effects of acupuncture on cocaine and alcohol dependence. For example, severe recidivist alcoholic patients treated with acupuncture specifically for the treatment of substance abuse reported less craving for alcohol, fewer drinking episodes, and required fewer admissions to the county detoxification center than did control patients who received acupuncture at nonspecific points [27]. Lipton et al. [32] also reported that patients receiving acupuncture treatment had significantly lower levels of cocaine metabolites than the control subjects. Recently, researchers, headed by S. Kelly Avants, from the division of substance abuse in the Department of Psychiatry at Yale University, divided 82 cocaine addicts into three groups. One third received acupuncture at four specific points around the outer ear, another third received "sham" acupuncture at sites on the ear that would be ineffective, and the remaining third received relaxation therapy consisting of viewing a relaxing video. Treatment sessions were five times a week and lasted eight weeks. The subjects' urine was tested three times a week for traces of cocaine. They found that patients assigned to receive true acupuncture had less cocaine use compared to the two other groups, and there were a higher percentage of patients in the acupuncture group who were clean from cocaine use by the last week of the study than in the two other groups [6].

The effects of acupuncture on drug addiction have also been verified by animal experiments. It has been well shown that acupuncture suppressed morphine withdrawal syndrome and alcohol-drinking behaviors in rats [33-35]. Furthermore, morphine-induced conditioned place preference can be successfully suppressed by 2 or 100 Hz electroacupuncture, a substitute for classic acupuncture [36, 37]. A recent study by Chae et al. [38] found that acupuncture at ST36, but not the other acupuncture points, significantly attenuated the expected increase in nicotineinduced locomotor sensitization to subsequent nicotine challenge. Behavioral response to nicotine challenge in the repeated nicotine treated group (control) was significantly intenser. Stimulation of acupuncture at ST36 just before nicotine challenge as well as during 3 days of withdrawal period completely blocked the effects of nicotine on locomotor activity during the 60 min testing period. In our laboratory, we also found that acupuncture applied at the BL.23 acupuncture point, a novel acupuncture point, could effectively suppress withdrawal syn‐ drome [39,40].

However, some large clinical trials have questioned the effectiveness of acupuncture for drug dependence. In these studies, the acupuncture treatment groups failed to show significant differences from the control group in the treatment of drug dependence [41]. One study has found that acupuncture offered no significant reduction of nicotine withdrawal symptoms or long-term improvement over placebo [42]. Bullock et al. performed a single-blind, random‐ ized, placebo-controlled study to evaluate auricular acupuncture in the treatment of cocaine addiction. Their study had 236 residential and 202 day treatment clients. They did not find any significant treatment differences between true and sham acupuncture. They also found no differences among the three dose levels of true acupuncture [43].The Cocaine Alternative Treatment Study (CATS) [44] was a large-scale, multi-site study. In this study, 620 patients addicted to cocaine were enrolled from six treatment sites; 412 of the patients were ''primary'' cocaine-dependent, and 208 were opiate-dependent and maintained on methadone. Patients were randomized to the three treatment conditions: auricular acupuncture, a needle-insertion control condition, and a relaxation control condition. Treatments were offered five times weekly for 8 weeks. The patients maintained on methadone received standard care as offered in their methadone program. Concurrent drug counseling was also offered to patients in all conditions. The primary outcome measure was cocaine use during treatment and at the 3- and 6-month postrandomization follow-up based on urine toxicology screens and retention in treatment. Results of urine samples showed a significant overall reduction in cocaine use, but no differences by treatment condition. There were also no differences between the conditions in treatment retention (44%–46% for the full 8 weeks). In the last week of treatment, 24, 31, and 29% of patients in auricular acupuncture, needle-insertion control, and relaxation control conditions, respectively, were abstinent from cocaine. This large study does not support the use of acupuncture as a stand-alone treatment for cocaine addiction.

A number of studies have examined the effects of acupuncture on cocaine and alcohol dependence. For example, severe recidivist alcoholic patients treated with acupuncture specifically for the treatment of substance abuse reported less craving for alcohol, fewer drinking episodes, and required fewer admissions to the county detoxification center than did control patients who received acupuncture at nonspecific points [27]. Lipton et al. [32] also reported that patients receiving acupuncture treatment had significantly lower levels of cocaine metabolites than the control subjects. Recently, researchers, headed by S. Kelly Avants, from the division of substance abuse in the Department of Psychiatry at Yale University, divided 82 cocaine addicts into three groups. One third received acupuncture at four specific points around the outer ear, another third received "sham" acupuncture at sites on the ear that would be ineffective, and the remaining third received relaxation therapy consisting of viewing a relaxing video. Treatment sessions were five times a week and lasted eight weeks. The subjects' urine was tested three times a week for traces of cocaine. They found that patients assigned to receive true acupuncture had less cocaine use compared to the two other groups, and there were a higher percentage of patients in the acupuncture group who were clean from

The effects of acupuncture on drug addiction have also been verified by animal experiments. It has been well shown that acupuncture suppressed morphine withdrawal syndrome and alcohol-drinking behaviors in rats [33-35]. Furthermore, morphine-induced conditioned place preference can be successfully suppressed by 2 or 100 Hz electroacupuncture, a substitute for classic acupuncture [36, 37]. A recent study by Chae et al. [38] found that acupuncture at ST36, but not the other acupuncture points, significantly attenuated the expected increase in nicotineinduced locomotor sensitization to subsequent nicotine challenge. Behavioral response to nicotine challenge in the repeated nicotine treated group (control) was significantly intenser. Stimulation of acupuncture at ST36 just before nicotine challenge as well as during 3 days of withdrawal period completely blocked the effects of nicotine on locomotor activity during the 60 min testing period. In our laboratory, we also found that acupuncture applied at the BL.23 acupuncture point, a novel acupuncture point, could effectively suppress withdrawal syn‐

However, some large clinical trials have questioned the effectiveness of acupuncture for drug dependence. In these studies, the acupuncture treatment groups failed to show significant differences from the control group in the treatment of drug dependence [41]. One study has found that acupuncture offered no significant reduction of nicotine withdrawal symptoms or long-term improvement over placebo [42]. Bullock et al. performed a single-blind, random‐ ized, placebo-controlled study to evaluate auricular acupuncture in the treatment of cocaine addiction. Their study had 236 residential and 202 day treatment clients. They did not find any significant treatment differences between true and sham acupuncture. They also found no differences among the three dose levels of true acupuncture [43].The Cocaine Alternative Treatment Study (CATS) [44] was a large-scale, multi-site study. In this study, 620 patients addicted to cocaine were enrolled from six treatment sites; 412 of the patients were ''primary'' cocaine-dependent, and 208 were opiate-dependent and maintained on methadone. Patients were randomized to the three treatment conditions: auricular acupuncture, a needle-insertion control condition, and a relaxation control condition. Treatments were offered five times weekly for 8 weeks. The patients maintained on methadone received standard care as offered

cocaine use by the last week of the study than in the two other groups [6].

200 Complementary Therapies for the Body, Mind and Soul

drome [39,40].

## **4. Effects of acupuncture on psychological symptoms associated with drug addiction**

Easing psychological symptoms associated with heroin use and heroin relapse is an important goal in the treatment of heroin dependence. Notably, as the course of withdrawal followed its natural history and acute symptoms abated, acupuncture continued to reduce anxiety and cravings associated with protracted withdrawal. In fact, patients who had completed addiction programs often continued to enjoy stress reduction induced by occasional "booster" acupunc‐ ture treatments. There are many ancient and contemporary papers reporting the successful use of acupuncture for the treatment of patients with depression and anxiety disorders [45-50]. Given that the prevalence of depression and anxiety is very high in cocaine and other drug addicts, and depression and anxiety after prolonged abstinence become the main factors contributing to drug relapse and craving, it is very meaningful to pay close attention to the effects of acupuncture on depression treatment among addicts. In addition, acupuncture has been used to improve psychological status and lessen fatigue [51]. Chang et al. conducted a three-arm randomized controlled trial (RCT) on residents of a homeless veteran rehabilitation program. Sixty-seven enrolled participants were randomly assigned to acupuncture, the relaxation response, or usual care. They found that craving and anxiety levels decreased significantly following one session of acupuncture [52]. In another small, randomized con‐ trolled trial, Allen et al. [53] compared symptoms of depression in an acupuncture group, placebo group, and a waitlist control group. The acupuncture group showed greater improve‐ ments in depressive scores than the placebo group and the waitlist control group. Roschke et al. [54] studied the effects of adding acupuncture to antidepressant treatment and found that the acupuncture in combination with antidepressant treatment improved the alleviation of depression course compared with pharmaceutical treatment alone. In a clinical trial using TAES for the suppression of opiate craving in humans, a total of 117 heroin addicts who had completed the process of detoxification for more than 1 month were recruited [55]. They were randomly and evenly assigned into four groups. Three groups received TAES treatment of different frequencies (2, 100, or 2/100 Hz). Self-sticking skin electrodes were placed on four acupoints: Hegu and Laogong (palmar side of the Hegu point) in the left (or right) hand to complete a circuit, and Neiguan and Weiguan in the opposite arm to complete a circuit. The control group was processed as in the previous groups except that the intensity was minimal (15 Hz, threshold stimulation for 3 min, and then switched to 1 mA thereafter) to serve as a mock TAES control. Visual analog scale (VAS) was used to assess the degree of craving. There was a very slow decline of the VAS in the mock TAES control group in a period of 1 month. A dramatic decline of the degree of craving was observed in the groups receiving 2 and 2/100 Hz electric stimulation, but not in the group receiving 100 Hz stimulation. These results observed in humans were in line with the findings obtained in the rat: low-frequency TAES is more effective than high-frequency TAES in suppressing the morphine-induced CPP [56].

However, some studies [6, 30, 57, 58] did not show favorable effects of acupuncture on psychological symptoms associated with opioid addiction (anxiety, depression, and craving). For example, Black et al. [59] conducted a randomized controlled study to test the effect of auricular acupuncture in the treatment of anxiety associated with withdrawal from psycho‐ active drugs. They found that auricular acupuncture was not more effective than sham or treatment setting control in reducing anxiety. We reviewed the clinical studies that have investigated the clinical effectiveness of acupuncture and focused on psychological symptoms associated with opioid addiction. The clinical studies published in Chinese language journals were assessed carefully and included in our systematical reviews. We found that eight studies [26, 29, 41, 44, 60-62,64] included heroin/opioid craving. Seven studies [27, 28, 32, 60-63] included anxiety. Two studies included depression [60, 65]. All of the four studies [44, 66-68] published in English language journals did not show favorable effects of acupuncture on psychological symptoms associated with opioid addiction (anxiety, depression, and craving). Many studies published in Chinese language journals supported the use of acupuncture for controlling psychological symptoms associated with opioid addiction: craving [26, 41, 63, 69,], anxiety [29, 32, 60, 62, 63, 70], and depression [60, 68].

Treatment retention and abstinence are more important goals for the treatment of drug dependence. Effectiveness of the treatment of psychological symptoms associated with drug addiction should be assessed by including longer-term follow-up data. In fact, to determine whether initial improvements from the treatment persist for a reasonable period of time, participant observation should last for at least 3 months. However, most of the studies we reviewed did not provide follow-up data. In these studies, the duration of acupuncture interventions was also shorter than 1 month. In fact, it is unclear whether the extent to which acupuncture has therapeutic effects depends on the duration and frequency of acupuncture. Arguably, longer treatment periods are required for acupuncture to have any chance of showing clinical effects. These variable factors should be taken into account when assessing the effects of acupuncture. Future studies should therefore have sufficiently large samples, extended treatment, and follow-up periods.

## **5. Possible mechanisms for the effectiveness of acupuncture on drug addiction**

It would be reasonable to suggest that an opioidergic mechanism is, at least partially, involved in mediating acupuncture antiwithdrawal. Han and his colleagues from Peking University China have made a detailed survey on the analgesic effect of EA. They found that analgesia induced by 100-Hz EA resulted from accelerating the release of dynorphin from the spinal cord of the rats [11, 71, 72]. In accord with this was the finding that the analgesic effect of 100- Hz EA observed in morphine-dependent rats could be blocked by a high dose of naloxone only [73]. On the other hand, dynorphin has been shown to be the endogenous ligand of the n-opioid receptor. Indeed, the withdrawal syndrome observed in rats dependent on morphine can be suppressed by high-frequency electroacupuncture, which accelerates the release of dynorphin in the spinal cord and brain [33, 70, 74]. Morphine-induced conditioned-place preference, an experimental model simulating the craving of heroin addicts, can be effectively suppressed by low-frequency electroacupuncture. This effect can be blocked by a small dose of naloxone, indicating the involvement of endogenous opioid peptides [36, 69]. Meanwhile, the clinical study by V. Clement-Jones et al. also showed that EA was associated with a rise in cerebrospinal fluid met-enkephalin levels in all addicts studied [67]. Recently, Wang et al. [75] found that a downregulation of preprodynorphin (PPD) mRNA level was observed in spinal cord, PAG, and hypothalamus 60 hours after the last morphine injection, which could be reversed by multiple sessions, but not a single session of EA. Accompanied with the decrease of PPD mRNA level, there was an upregulation of p-CREB in the three CNS regions, which was abolished by 100 Hz EA treatment. These findings suggest that downregulation of p-CREB and acceleration of dynorphin synthesis in spinal cord, PAG, and hypothalamus may be implicated in the cumulative effect of multiple 100Hz EA treatment for opioid detoxification.

was a very slow decline of the VAS in the mock TAES control group in a period of 1 month. A dramatic decline of the degree of craving was observed in the groups receiving 2 and 2/100 Hz electric stimulation, but not in the group receiving 100 Hz stimulation. These results observed in humans were in line with the findings obtained in the rat: low-frequency TAES is more effective than high-frequency TAES in suppressing the morphine-induced CPP [56]. However, some studies [6, 30, 57, 58] did not show favorable effects of acupuncture on psychological symptoms associated with opioid addiction (anxiety, depression, and craving). For example, Black et al. [59] conducted a randomized controlled study to test the effect of auricular acupuncture in the treatment of anxiety associated with withdrawal from psycho‐ active drugs. They found that auricular acupuncture was not more effective than sham or treatment setting control in reducing anxiety. We reviewed the clinical studies that have investigated the clinical effectiveness of acupuncture and focused on psychological symptoms associated with opioid addiction. The clinical studies published in Chinese language journals were assessed carefully and included in our systematical reviews. We found that eight studies [26, 29, 41, 44, 60-62,64] included heroin/opioid craving. Seven studies [27, 28, 32, 60-63] included anxiety. Two studies included depression [60, 65]. All of the four studies [44, 66-68] published in English language journals did not show favorable effects of acupuncture on psychological symptoms associated with opioid addiction (anxiety, depression, and craving). Many studies published in Chinese language journals supported the use of acupuncture for controlling psychological symptoms associated with opioid addiction: craving [26, 41, 63, 69,],

Treatment retention and abstinence are more important goals for the treatment of drug dependence. Effectiveness of the treatment of psychological symptoms associated with drug addiction should be assessed by including longer-term follow-up data. In fact, to determine whether initial improvements from the treatment persist for a reasonable period of time, participant observation should last for at least 3 months. However, most of the studies we reviewed did not provide follow-up data. In these studies, the duration of acupuncture interventions was also shorter than 1 month. In fact, it is unclear whether the extent to which acupuncture has therapeutic effects depends on the duration and frequency of acupuncture. Arguably, longer treatment periods are required for acupuncture to have any chance of showing clinical effects. These variable factors should be taken into account when assessing the effects of acupuncture. Future studies should therefore have sufficiently large samples,

**5. Possible mechanisms for the effectiveness of acupuncture on drug**

It would be reasonable to suggest that an opioidergic mechanism is, at least partially, involved in mediating acupuncture antiwithdrawal. Han and his colleagues from Peking University China have made a detailed survey on the analgesic effect of EA. They found that analgesia induced by 100-Hz EA resulted from accelerating the release of dynorphin from the spinal cord of the rats [11, 71, 72]. In accord with this was the finding that the analgesic effect of 100- Hz EA observed in morphine-dependent rats could be blocked by a high dose of naloxone

anxiety [29, 32, 60, 62, 63, 70], and depression [60, 68].

202 Complementary Therapies for the Body, Mind and Soul

extended treatment, and follow-up periods.

**addiction**

The mesolimbic dopamine system originates in the ventral tegmental area (VTA) and projects to regions that include the nucleus accumbens and prefrontal cortex, which are believed to play a pivotal role in the development of opiate addiction [20]. Opiate abuse-induced changes in the levels of dopamine in the brain are associated with feelings of well-being and pleasure, providing positive reinforcement of continued opiate abuse [76, 39]. Conversely, withdrawal from chronic opiate administration reduces dopamine outflow in the nucleus accumbens [40, 77]. Furthermore, in the treatment of drug craving and relapse to drug use, the core symptoms of addiction, a non-endorphin-mediated mechanism is probably involved. Lu et al. [78] examined alterations in the firing rate of dopaminergic neurons by means of extracellular recording following chronic morphine exposure and applied 100 Hz electroacupuncture treatment to reverse the reduced firing rate of these neurons. They found that the electrophy‐ siological response of VTA DA neurons to morphine was markedly reduced in chronic morphine-treated rats compared to saline-treated controls. A substantial recovery of the reactivity of VTA DA neurons to morphine was observed in rats that received 100 Hz EA for 10 days. Evidence also indicates that acupuncture acts on the nucleus accumbens to inhibit the elevation in dopamine [79, 80]. Yoon et al. demonstrated the acupuncture-mediated inhibition of ethanol-induced dopamine released in the rat nucleus accumbens through the GABAB receptor [80]. Chae et al. showed that acupuncture treatment at ST.36 attenuated the expected increase in nicotine-induced locomotor activity by reducing postsynaptic neuronal activity in the nucleus and striatum [38].

ΔFosB and FosB are members of the Fos family of transcription factors implicated in neural plasticity in drug addiction. Li et al. [81] found that the intake of and preference for ethanol in rats under 100 Hz, but not 2 Hz electroacupuncture, regiment were sharply reduced. The reduction was maintained for at least 72 hours after the termination of electroacupuncture treatment. Conversely, 100 Hz electroacupuncture did not alter the intake of and preference for the natural rewarding agent sucrose. Additionally, FosB/ΔFosB levels in the prefrontal cortex, striatal region, and the posterior region of ventral tegmental area were increased following excessive ethanol consumption, but were reduced after 6-day 100 Hz electroacu‐ puncture. Interestingly, EA can inhibit CB1 receptor upregulation in the prefrontal cortex, striatum, hippocampus, amygdala, and ventral tegmental area in ethanol-withdrawn mice [82]. Furthermore, extracellular signal-regulated kinase (ERK) plays a role in neuronal changes induced by repeated drug exposure. EA can reverse ethanol-induced locomotor sensitization and subsequent ERK expression in mice [83]. These results suggest that acupuncture could play an important role in suppressing the potentiating effects of ethanol and other drugs.

Our recent study [41] showed that acupuncture attenuated elevated c-fos expression in the central nucleus of the amygdala (CeA) during morphine withdrawal in rats. Some studies emphasize that the motivational components of opiate withdrawal appear to be centrally mediated by limbic structures such as the nucleus accumbens and amygdale [2-4]. Therefore, elevated c-fos expression in the CeA might be associated with the motivational components of opiate withdrawal. Our observation that acupuncture suppressed elevated c-fos expression in the CeA indicated that acupuncture might have some therapeutic effects in the treatment of the negative motivations of opiate withdrawal. Of course, further studies must be performed to clarify this issue. In addition, the CeA and the basolateral amygdala have been extensively and differentially involved in associative learning and memory processes, attributing affective salience to environmental stimuli paired with drug effects [5]. One theory of the neural mechanisms of drug abuse focuses on various learning and memory systems in which the normal functions of these complex neural circuits become subverted leading to compulsive drug-seeking behaviors [84, 85]. In this model, drugs of abuse initiate plasticity mechanisms in different learning and memory systems that come to control behaviors of the individual over other preexisting memories. Experience with addictive drugs are encoded and stored like other experiences, except that drugs of abuse only mimic a subset of the actions of natural reinforcers in the brain. Acupuncture can affect learning and memorizing ability [1, 7, 86, 87]. Further work is needed to emphasize whether acupuncture can re-encode experience with addictive drug via affecting learning and memory systems, and modify the addictive behav‐ iors. The amygdala acquires information that promotes approach and interaction with drugassociated stimuli. We also need to know which role the amygdale plays when acupuncture stimulation affects drug-associated learning and memory.

## **6. Discussion**

In terms of lives and productivity, drug addiction remains one of the most serious threats to our public health. Addiction can be defined as the loss of control over drug use, or the compulsive seeking and taking of a drug regardless of the consequences. Available treatments for addiction remain inadequately effective for most individuals. Incorporating acupuncture into existing therapies offers a promising approach. Acupuncture has been widely recognized as a valuable, readily available, and safe means of health care. It is effective, inexpensive, and requires only simple equipment. In this review, we identify and summarize the evidence about the possible clinical effectiveness of acupuncture on drug addiction, including withdrawal symptoms, drug craving, depression, and anxiety. We also discuss the theory and possible mechanisms for the effectiveness of acupuncture. Some animal and clinical studies have provided supporting evidence for the promising effects of acupuncture. Unfortunately, the data do not allow us to make conclusions that acupuncture was an effective treatment for drug addiction. The evidence for its effectiveness has been inconclusive and difficult to interpret [63]. Some of the clinical studies were unable to detect statistically significant differences in treatment efficacy between their acupuncture treatment and control groups [66-68]. In addition, there are few randomized controlled clinical trials of acupuncture treatment for drug addiction, and the methodological methods used in several clinical trials of acupuncture treatment for drug dependence can be criticized for their poor quality. The quality issues include the following: small numbers of patients, no control subjects, lack of randomized assignment, lack of details regarding specific point locations for needle insertion, and no specification regarding the degree of blinding among research subjects.

following excessive ethanol consumption, but were reduced after 6-day 100 Hz electroacu‐ puncture. Interestingly, EA can inhibit CB1 receptor upregulation in the prefrontal cortex, striatum, hippocampus, amygdala, and ventral tegmental area in ethanol-withdrawn mice [82]. Furthermore, extracellular signal-regulated kinase (ERK) plays a role in neuronal changes induced by repeated drug exposure. EA can reverse ethanol-induced locomotor sensitization and subsequent ERK expression in mice [83]. These results suggest that acupuncture could play an important role in suppressing the potentiating effects of ethanol and other drugs.

204 Complementary Therapies for the Body, Mind and Soul

Our recent study [41] showed that acupuncture attenuated elevated c-fos expression in the central nucleus of the amygdala (CeA) during morphine withdrawal in rats. Some studies emphasize that the motivational components of opiate withdrawal appear to be centrally mediated by limbic structures such as the nucleus accumbens and amygdale [2-4]. Therefore, elevated c-fos expression in the CeA might be associated with the motivational components of opiate withdrawal. Our observation that acupuncture suppressed elevated c-fos expression in the CeA indicated that acupuncture might have some therapeutic effects in the treatment of the negative motivations of opiate withdrawal. Of course, further studies must be performed to clarify this issue. In addition, the CeA and the basolateral amygdala have been extensively and differentially involved in associative learning and memory processes, attributing affective salience to environmental stimuli paired with drug effects [5]. One theory of the neural mechanisms of drug abuse focuses on various learning and memory systems in which the normal functions of these complex neural circuits become subverted leading to compulsive drug-seeking behaviors [84, 85]. In this model, drugs of abuse initiate plasticity mechanisms in different learning and memory systems that come to control behaviors of the individual over other preexisting memories. Experience with addictive drugs are encoded and stored like other experiences, except that drugs of abuse only mimic a subset of the actions of natural reinforcers in the brain. Acupuncture can affect learning and memorizing ability [1, 7, 86, 87]. Further work is needed to emphasize whether acupuncture can re-encode experience with addictive drug via affecting learning and memory systems, and modify the addictive behav‐ iors. The amygdala acquires information that promotes approach and interaction with drugassociated stimuli. We also need to know which role the amygdale plays when acupuncture

In terms of lives and productivity, drug addiction remains one of the most serious threats to our public health. Addiction can be defined as the loss of control over drug use, or the compulsive seeking and taking of a drug regardless of the consequences. Available treatments for addiction remain inadequately effective for most individuals. Incorporating acupuncture into existing therapies offers a promising approach. Acupuncture has been widely recognized as a valuable, readily available, and safe means of health care. It is effective, inexpensive, and requires only simple equipment. In this review, we identify and summarize the evidence about

stimulation affects drug-associated learning and memory.

**6. Discussion**

In fact, there are some variable factors that need to be taken into account when assessing the effects of acupuncture on drug addiction. (1) The study protocol may influence the assessment of effectiveness of acupuncture. Methods and research designs have been issues of debate among acupuncture clinicians and researchers [88]. For a methodological perspective, randomized controlled trails are considered the gold standard in terms of identifying differ‐ ences in treatment efficacy [89]. However, unlike the evaluation of a new drug, randomized controlled trials of acupuncture are extremely difficult to conduct, particularly if they have to be blind in design and acupuncture has to be compared with a placebo [90]. The efficacy of acupuncture is difficult to study empirically because of the fundamental divergence between the two schools of thought. The gold standard in Western science is randomized, double-blind, and controlled trails, utilizing one specific protocol for each condition. Randomized controlled trails can be used to answer questions about most clinical problems. However, this approach is not always a practical and cost-effective solution. Sometimes randomized controlled trails are open to error; for instance, patient preference may have an effect on the results as may certain cultural environments. In addition, in some Asian countries such as China where acupuncture is widely used, most patients know a great deal about acupuncture, including the special sensation that should be felt after insertion or during manipulation of the needle. Although various "sham" or "placebo" acupuncture procedures have been designed, they are not easy to perform in these countries. Moreover, acupuncturists consider these procedures unethical because they are already convinced that acupuncture is effective. In fact, most of the placebo-controlled clinical trials have been undertaken in countries where there is skepticism about acupuncture, as well as considerable interest. (2) Another difficulty in evaluating acupuncture practice is that the therapeutic effect depends greatly on the proficiency of the acupuncturists. Their ability and skill in selecting and locating the acupuncture points and in manipulating the needles are different. Needling techniques of inserting, retaining, stimulat‐ ing, and withdrawing are difficult to standardize. This may partly explain the disparities or inconsistencies in the results reported by different authors, even when their studies were

carried out on equally sound methodological bases. (3)In traditional Chinese medical system, such as acupuncture, where each individual is treated according to specific conditions and symptoms, it may be invalid to use the same protocol for every condition. Individualized protocols are critical to the success of the acupuncture treatment. For example, acupuncture stimulation typically elicits a composite of sensations termed deqi, manifesting as soreness, numbness, heaviness, and distention [91]. A body of clinical and experimental evidence indicates that the presence of the deqi sensation is a prerequisite for, and often an indicator of, a clinical acupuncture effect. Traditionally, patients are asked to remain aware of the sensation during acupuncture treatment. Deqi may be an important variable in studies of the efficacy and mechanism of the action of acupuncture treatment. Our previous study showed that the deqi sensations of heroin addicts were significantly higher than those of healthy subjects during acupuncture stimulation, indicating that heroin addicts are "good" responders to acupuncture stimulation [92]. (4) Acupuncture was developed as a branch of traditional Chinese medicine on the basis of oriental philosophy, which takes a holistic approach to regulating the balance of the human body. (Several different schools of acupuncture exist, each with its own principles.) These principles may vary with the types of acupuncture being investigated. The inconsistency in treatment protocols between studies, or the use of combined therapies, makes it impossible to draw a strong causal relationship between therapy and its treatment effect, thus making replication of studies difficult. To this end, traditional knowledge and experience of acupuncture should be duly represented by the investigation team when research is proposed, prepared, and conducted. A good clinical study on acupuncture may be conducted with the understanding and integration of both traditional and modern knowledge of medicine; (5) Most of the clinical research on acupuncture in the United States focused on auricular acupuncture, which is simply the insertion of acupuncture needles into prespecified locations in the ear, whereas studies from China used body acupuncture to treat opiate addiction. These findings are intriguing considering that acupuncture on body and auricular points exhibited different efficacies. According to our clinical experience and the theory of traditional Chinese medicine, body acupuncture may need more attention. Some acupuncture points represent discrete locations in the body, where manual or electrical stimulation can exhibit therapeutic effects on cocaine and other drug addiction [26, 28, 60, 61, 93]. Table 1 provides the summary of main acupoints/sites selected in the reviewed studies. In China, body acupuncture, rather than ear acupuncture, was commonly used for the treatment of drug addiction [26, 28, 60]. The acupuncture points most frequently selected are Zusanli (ST.36), Sanyinjiao (SP.6), Neiguan (PC.6), Shenmen (HT.7), Laogong (PC.8), Waiguan (TE.5), and Hegu (LI.15), located on the four limbs. In our recent work, we showed for the first time that acupuncture applied at the BL.23 acupuncture point, located on the back and commonly used for analgesia and sedation in our clinic, could effectively suppress withdrawal syndrome [40, 41]. Clinically, BL.23 could provide us with a new selection of effective acupuncture points for successful treatment of drug addiction. Further studies on the synergistic combination of BL. 23 and other effective acupuncture points, such as Zusanli (ST.36) and Sanyinjiao (SP.6), could assist acupuncturists to use a balanced and appropriate choice for combining points in the treatment of addicts.


**Table 1.** Summary of main acupoints/sites selected in the reviewed studies

carried out on equally sound methodological bases. (3)In traditional Chinese medical system, such as acupuncture, where each individual is treated according to specific conditions and symptoms, it may be invalid to use the same protocol for every condition. Individualized protocols are critical to the success of the acupuncture treatment. For example, acupuncture stimulation typically elicits a composite of sensations termed deqi, manifesting as soreness, numbness, heaviness, and distention [91]. A body of clinical and experimental evidence indicates that the presence of the deqi sensation is a prerequisite for, and often an indicator of, a clinical acupuncture effect. Traditionally, patients are asked to remain aware of the sensation during acupuncture treatment. Deqi may be an important variable in studies of the efficacy and mechanism of the action of acupuncture treatment. Our previous study showed that the deqi sensations of heroin addicts were significantly higher than those of healthy subjects during acupuncture stimulation, indicating that heroin addicts are "good" responders to acupuncture stimulation [92]. (4) Acupuncture was developed as a branch of traditional Chinese medicine on the basis of oriental philosophy, which takes a holistic approach to regulating the balance of the human body. (Several different schools of acupuncture exist, each with its own principles.) These principles may vary with the types of acupuncture being investigated. The inconsistency in treatment protocols between studies, or the use of combined therapies, makes it impossible to draw a strong causal relationship between therapy and its treatment effect, thus making replication of studies difficult. To this end, traditional knowledge and experience of acupuncture should be duly represented by the investigation team when research is proposed, prepared, and conducted. A good clinical study on acupuncture may be conducted with the understanding and integration of both traditional and modern knowledge of medicine; (5) Most of the clinical research on acupuncture in the United States focused on auricular acupuncture, which is simply the insertion of acupuncture needles into prespecified locations in the ear, whereas studies from China used body acupuncture to treat opiate addiction. These findings are intriguing considering that acupuncture on body and auricular points exhibited different efficacies. According to our clinical experience and the theory of traditional Chinese medicine, body acupuncture may need more attention. Some acupuncture points represent discrete locations in the body, where manual or electrical stimulation can exhibit therapeutic effects on cocaine and other drug addiction [26, 28, 60, 61, 93]. Table 1 provides the summary of main acupoints/sites selected in the reviewed studies. In China, body acupuncture, rather than ear acupuncture, was commonly used for the treatment of drug addiction [26, 28, 60]. The acupuncture points most frequently selected are Zusanli (ST.36), Sanyinjiao (SP.6), Neiguan (PC.6), Shenmen (HT.7), Laogong (PC.8), Waiguan (TE.5), and Hegu (LI.15), located on the four limbs. In our recent work, we showed for the first time that acupuncture applied at the BL.23 acupuncture point, located on the back and commonly used for analgesia and sedation in our clinic, could effectively suppress withdrawal syndrome [40, 41]. Clinically, BL.23 could provide us with a new selection of effective acupuncture points for successful treatment of drug addiction. Further studies on the synergistic combination of BL. 23 and other effective acupuncture points, such as Zusanli (ST.36) and Sanyinjiao (SP.6), could assist acupuncturists to use a balanced and appropriate choice for combining points in the

206 Complementary Therapies for the Body, Mind and Soul

treatment of addicts.

In summary, acupuncture offer some advantages over existing pharmacological interventions: they are safer, have fewer side effects, and are less expensive. Since deteriorating health often accompanies long-term use of addictive drugs, pharmaceutical interventions with harsh side effects can be detrimental to the general health of long-term drug users. In contrast, acupunc‐ ture can enhance immune function and increase metabolism in organs necessary to fight infections and various acute and chronic illnesses. Although the definitive role of acupuncture in the treatment of drug addiction has yet to be established, its basic research and clinical data reviewed here justify further clinical trials to systematically examine the efficacy of acupunc‐ ture in treating various conditions related to drug addiction such as withdrawal symptoms, drug craving, anxiety, and depression. The next important step in acupuncture research is to get a better understanding of the neurochemical mechanism of acupuncture in order that the therapeutic effects of acupuncture can be further improved. Also scientifically conducted clinical research is needed to examine the effectiveness of acupuncture treatment of drug addicts. As we mentioned in this review, it has proved difficult to apply and integrate the basic principles and methodology of modern science that ensure the reliability of research subjects to clinical studies on acupuncture. However, researchers should be encouraged to ensure the highest possible standards of study design and reporting in future research in order to improve the evidence base in this field.

## **Acknowledgements**

This work was supported by NSFC (81373753), Shanghai Natural Science Foundation (13ZR1441900), and Innovation Program of Shanghai Municipal Education Commission (11YZ68). We thank F.Q. Zhang for helpful comments on the manuscript.

## **Author details**

Anfeng Xiang, Boyuan Zhang and Sheng Liu\*

\*Address all correspondence to: lskingcn@hotmail.com

Shanghai University of Traditional Chinese Medicine, Shanghai, China

## **References**

[1] Wang L, Tang C, Lai X. Effects of electroacupuncture on learning, memory and for‐ mation system of free radicals in brain tissues of vascular dementia model rats. J Tra‐ dit Chin Med 2004;24:140-3. DOI:10.3969/j.issn.0255-2922.2004.02.021

[2] Heinrichs SC, Menzaghi F, Schulteis G, et al. Suppression of corticotrophin-releasing factor in the amygdala attenuates aversive consequences of morphine withdrawal. Behav Pharmacol 1995;6:74-80.DOI:10.1097/00008877-199501000-00011

In summary, acupuncture offer some advantages over existing pharmacological interventions: they are safer, have fewer side effects, and are less expensive. Since deteriorating health often accompanies long-term use of addictive drugs, pharmaceutical interventions with harsh side effects can be detrimental to the general health of long-term drug users. In contrast, acupunc‐ ture can enhance immune function and increase metabolism in organs necessary to fight infections and various acute and chronic illnesses. Although the definitive role of acupuncture in the treatment of drug addiction has yet to be established, its basic research and clinical data reviewed here justify further clinical trials to systematically examine the efficacy of acupunc‐ ture in treating various conditions related to drug addiction such as withdrawal symptoms, drug craving, anxiety, and depression. The next important step in acupuncture research is to get a better understanding of the neurochemical mechanism of acupuncture in order that the therapeutic effects of acupuncture can be further improved. Also scientifically conducted clinical research is needed to examine the effectiveness of acupuncture treatment of drug addicts. As we mentioned in this review, it has proved difficult to apply and integrate the basic principles and methodology of modern science that ensure the reliability of research subjects to clinical studies on acupuncture. However, researchers should be encouraged to ensure the highest possible standards of study design and reporting in future research in order to improve

This work was supported by NSFC (81373753), Shanghai Natural Science Foundation (13ZR1441900), and Innovation Program of Shanghai Municipal Education Commission

[1] Wang L, Tang C, Lai X. Effects of electroacupuncture on learning, memory and for‐ mation system of free radicals in brain tissues of vascular dementia model rats. J Tra‐

dit Chin Med 2004;24:140-3. DOI:10.3969/j.issn.0255-2922.2004.02.021

(11YZ68). We thank F.Q. Zhang for helpful comments on the manuscript.

Shanghai University of Traditional Chinese Medicine, Shanghai, China

the evidence base in this field.

208 Complementary Therapies for the Body, Mind and Soul

**Acknowledgements**

**Author details**

**References**

Anfeng Xiang, Boyuan Zhang and Sheng Liu\*

\*Address all correspondence to: lskingcn@hotmail.com


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214 Complementary Therapies for the Body, Mind and Soul


**Section 3**
