Preparing for the Opioid Patient: The Future of the Acupuncture Profession

In the future there will be many more clients with opioid addictions in acupuncture practices. Acupuncture is being promoted as an excellent resource to help with recovery from opioid addiction. It is invaluable for the acute phases of detoxification using the NADA protocol, and can also be a safe adjunct to help with early rehabilitation and abstinence. We need to be aware of a wide variety of unique health risks, which are more common in this population.

Some are physical or mental health conditions, requiring prompt referral and treatment. Other issues will need close monitoring and follow-up. Some situations can affect our own health and wellbeing. Acupuncturists may provide important continuity of care during the recovery process.

Acute Opioid Withdrawal

Narcotic withdrawal is uncomfortable, but rarely medically serious. Many of the symptoms can respond quickly and effectively to acupuncture treatment. Common withdrawal symptoms are related to autonomic nervous system dysfunction.

These present as nausea, vomiting, diarrhea, thermoderegulation, insomnia, muscle twitching, yawning, dysphoria and anxiety. Increased pulse and blood pressure are frequent withdrawal symptoms. Most clients can tolerate this without any problem, but some may have pre-existing conditions, which can be exacerbated by unstable blood pressure or pulse.

Some opioid addicted clients may be managed medically with the substitution of a longer acting, less reinforcing equivalent such as Buprenorphine or Methadone. Buprenorphine might be used alone (Subutex), or in combination with naloxone (Suboxone).

These medications are then tapered for eventual withdrawal, or symptom control. There are specific training guidelines required for physicians to be able to prescribe and manage these medications. Buprenorphine use in managing withdrawal symptoms consists of three stages:

1. Acute/induction (onset of withdrawal symptoms, until 3-7 days).
2. Stabilization (1-2 months). Using the lowest dose to minimize both withdrawal symptoms and side effects of Buprenorphine (typically sleep disturbance, headache, anxiety or depression).
3. Maintenance (undefined to indefinite). These medications can then be gradually tapered for eventual withdrawal or symptom control. This requires close allopathic follow-up.

Opioid addicted clients detoxing from additional substances, such as alcohol and/or benzodiazapines (e.g. valium, ativan, lunesta), can experience more medically serious withdrawal symptoms: unstable blood pressure, delirium, or seizures. These clients should be admitted to an inpatient setting for acute detoxification.

I recommend checking and documenting blood pressure and pulse (allopathic pulse measurement = beats/minute) at the beginning and end of each treatment for someone who is actively experiencing detoxification. If these vital signs are severely or persistently abnormal, seek and facilitate allopathic care. This is especially important for clients with pre-existing treated hypertension, coronary artery disease, or stroke.

Recovering opioid clients may continue to come to our practices for ongoing care. Many of these clients may be immuno-compromised. They are at higher risk for being Hepatitis C or HIV positive (either diagnosed or undiagnosed). Some clients may be receiving immuno-suppressive medications for other health conditions. Poor nutrition is another factor affecting immune status.

In these clients a persistent cough, new headaches, change in memory or concentration, fevers, fatigue, lymphadenopathy or new masses, can all be signs of potentially serious health issues. It is always "ok" to ask for help if you are uncertain or intuitively uncomfortable with some aspect of a client's situation.

Why A Full Patient History is Important

Be alert to mental health issues. Depression can be exacerbated by recovery, especially if narcotics were used for "self-medication". Anxiety or depression can also be worsened by the challenges and stresses of the recovery process. Checking for support systems may uncover risks for domestic abuse, unsafe home environment or homelessness. Have easy access to resources for mental health emergencies. Consider having social service referral information available, if a client needs or wants it.

A Chinese medicine holistic treatment approach mandates a detailed history. At times, this may allow access to information which is legally or ethically sensitive. It can challenge us on issues of confidentiality and disclosure. It is invaluable to proactively seek resources for clarifying legal requirements and ethical boundaries.

The Glove Debate

We need to also think carefully about our blood-born pathogen training. There will be situations which put us and our clients at increased risk of blood born pathogen exposure and possibly transmission.

An important example is whether or not to use gloves in our acupuncture practices. Some of us prefer direct skin contact, as we assess our clients. This helps us as we palpate, then plan and place our acupuncture treatments. Hara and pulse diagnostic systems depend on accurate energetic assessment, and feedback. Using gloves may seem like a significant barrier to using our skills effectively. I have personally acknowledged and struggled with this issue for many years in my own acupuncture practice.

Participation in community-style NADA treatments, will likely include clients who are Hepatitis C or HIV positive. Do we meticulously cleanse our hands each time we touch another person, both inserting and taking out treatments? If we use gloves, do we re-glove every time? I have volunteered in community style "drop in" clinics where the number of participants, the time they arrive, and the number of volunteer staff is unpredictable, and this can be a real challenge.

We also need to consider the hepatitis B vaccine for ourselves. If we have had the series of vaccines – are we protected? Have we had a post-vaccine titer? If we had not received the vaccine – do we want to reconsider this? How do we handle needle-sticks in our practice? Over time, more clients may come to our clinics as part of court-mandated treatment. The legal system may offer treatment instead of incarceration, to selected individuals.

The Consequences of Free Services

Acupuncture can be an excellent addition to a broader treatment approach including outpatient addiction counseling. However this has implications for client levels of motivation/participation, compared to our other self-pay clients, who use our services as part of a "wellness approach."

How do we handle "no-shows"? If a client cannot drive, misses a ride, is delayed or comes in late – do we treat still them? This can be one of the most vexing aspects to running a practice. Do we accommodate (or enable?) our late or no-show clients, vs. accepting the financial and time/energy realities of running a viable practice? Having a thoughtful and fair policy in place benefits all of our clients and helps us set firm boundaries.

It has been gratifying to see a movement towards including acupuncture as part of comprehensive approach to pain management. Opioid overuse and addiction is part of this broader policy shift. This support for including acupuncture, challenges us to become better trained in many areas.

I hope that this article supports us in finding ways to optimize care in this unique population of individuals.

Resources

1. Rakel R., et al. Textbook of Family Medicine, 9th edition. Philadelphia: Saunders, 2016.
2. Smith M, et al. Family Medicine, Ambulatory Care and Prevention, 6th edition. New York: McGraw-Hill Education, 2014.