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PG.4TRADITIONAL AND MODERN PHARMACOGNOSY:PERSPECTIVES FROM CHINESE AND WESTERN HERBAL MEDICINEDr. Er ic Brand, L .Ac. , PhD.

PG.8USING ACUPUNCTURE TO TREAT CHEMOTHERAPY-INDUCED PE-RIPHERAL NEUROPATHYHeidi Bart let t ,L .Ac.

PG.15NEUROPUNCTURE: SOLIDIFYING ACUPUNCTURE’S AUTHENTICITYDr. Michael Corradino,DAOM, MTOM,L.Ac.

PG.18MOXIBUSTION THERAPY IN THE TREATMENT OF RADIATION FI -BROSIS OF THE THROATDr.Bianca Di Giu l io ,DAOM,L.Ac.Dr. James Munson,DAOM,L.Ac.

PG.22AN INTERDISCIPLINARY PERSPEC-TIVE ON THE OPIOID CRISISElena Roemer

PG.29DISCUSSIONS ON GUI ZHI JIA LONG GU MU LI TANG: APPLICA-TIONS FOR TREATMENT OF TRAU-MA AND SUBSTANCE ABUSEBenjamin Zappin,L .Ac.

PG.32“SHEN-OCIDE”: TREATING THE PSYCHOSPIRITUAL ASPECTS OF OPIOID ADDICTION WITH ACU-PUNCTURE AND CHINESE MEDI-CINEMary E l i zabeth Wakef ie ld, L .Ac. ,M. S . ,M.M. ,Dipl .Ac. ,NCCAOM

PG.40CAN ACUPUNCTURE BIO-HACK THE AUTONOMIC NERVOUS SYSTEM AND DOWN-REGULATE INFLAMMATION? Dr. Sharon Hennessey,DAOM,L.Ac.

We are thr i l led to br ing you th is i ssue of the Journal of Acupuncture and Integrat ive Medic ine (JAIM) , former ly the Cal i forn ia Journal of Or ienta l Medic ine (CJOM).

As acupuncture f inds i ts way into more hospi ta ls and integrat ive medica l set t ings , pat ient- focused care i s no longer an ideal , but a new - and ref reshing - rea l i ty. Pat ients are beginning to re ly not just on thei r doctor, but on a heal thcare team, which may inc lude a nutr i t ionis t , therapist , acupunctur is t , ch i ropractor, and naturo-path, just to name a few.

Last Fa l l , our edi tor ia l team sat down to decide how we would br ing th is expanded th ink ing to CJOM. The answers were c lear : F i rs t , to int roduce more integrat ive medica l content , thereby drawing in readers f rom across a l l medica l profess ions . Second, we would give CJOM a f resh look and feel that was modern yet medica l , whi le acknowledging our 20+ years in publ icat ion. Thi rd, we would choose a name that ref lects the move towards integrat ion.

As you know, our country i s fac ing an epidemic of mass proport ion: the over-use, over-prescr ipt ion, and overdos ing of opio ids . We have devoted th is i ssue to answer ing the quest ion of how acupuncture and herbal medic ine can address pain management and the opioid cr is i s . The authors conta ined here in have wr i t ten incredible ar t ic les deta i l ing both thei r research and thei r exper iences. We hope you learn f rom them and can apply what you learn to your own pract ices .

Acupuncture medic ine has such a r ich , deta i led h is tory and the best way to cont inue that h is tory i s to share our knowledge f reely and wi l l ingly!

In heal th ,

Dr. Jordan Wheeler, L .Ac. & Jess ica WakemanCo-Editors- in-Chief

MISSION STATEMENTThe Cal i forn ia State Or ienta l Medica l Associat ion (CSOMA) is a profess ional associat ion of

l icensed acupunctur is ts and supporters of acupuncture, dedicated to the preservat ion, advancement and integrat ion of the ar t , sc ience, and pract ice of a l l branches of acupuncture medic ine into the modern heal thcare

model , in a car ing and eth ica l manner, thereby enhancing the heal th and wel l -being of the genera l publ ic .

Pictured lef t to r ight : Robyn “Ra” Adcock (Publ isher )Dr. Jordan WheelerJess ica Wakeman

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Editors in ChiefDr. Jordan Wheeler, DACM, L .Ac.Jess ica Wakeman

Execut ive Di rector & Publ isherRobyn “Ra” Adcock, L .Ac.

Market ing DirectorKim Neuman, L .Ac.

Graphic Des ignerDarren Samuel

Associate Edi torsDr. Sharon Hennessey, DAOM, L .Ac.Dr. Tamsin Lee DAOM, L .Ac.Michael Morgan, L .Ac.I lana Murphy, L .Ac.Emi ly Sablosky, L .Ac. , CMT

Subscr ipt ionsPubl ished annual ly and dis t r ibuted nat ionwide to l icensed acupunctur-i s ts , a l l ied medica l profess ionals , and students .

Contact CSOMA at :548 Market St reet #68552San Francisco, CA 94104Phone/Fax: (800) 477-4564Web: csomaonl ine.orgE-mai l : in fo@csomaonl ine.org

JAIM is a publ icat ion of the Cal i forn ia State Or ienta l Medica l Associat ion (CSOMA). Al l ar t i -c les represent the opin ions of the authors and do not necessar i ly ref lect the off ic ia l pol icy of CSO-MA, unless th is i s c lear ly speci f ied. The presence of an advert isement , let ter, or ar t ic le in JAIM does not const i tute an endorsement of the product or ideas represented there-in .

Copyr ight © 2018 by CSOMAAl l r ights reserved. NO part of th is publ icat ion may be reproduced, s tored in a ret r ieva l system, or t ransmit ted in any form or by any means, e lect ronic , mechanica l , pho-tocopying, recording, or otherwise, wi thout pr ior wr i t ten permiss ion f rom the publ isher. JAIM st r ives to present readers wi th a fa i r, ba lanced, and independent pub-l icat ion. For more in format ion on our pol ic ies regarding conf l ic t of interest , p lease contact the edi tor at ja im@csomaonl ine.org.

ISSN 1090-1965

The t imeless human quest to d is -cover natura l products that can a l lev iate d isease and suffer ing has caused pharmacognosy to be descr ibed as the “oldest modern sc ience.” 1 The use of p lant , an imal , and minera l products in the t reat-ment of d isease has been docu-mented wor ldwide for thousands of years , and t rade in medic ina l prod-ucts between cul tures dates back to anc ient t imes. Over the course of h is tory, pharmacognosy has evolved cons iderably fo l lowing advances in d isc ip l ines such as taxonomy, agronomy, and chemist ry, and t re-mendous divers i ty can be seen in the pre-modern approaches used by d i fferent cu l tures to eva luate and apply natura l medic ines . The word pharmacognosy, which is der ived f rom the Greek words “pharmakon” (drug) and “gno-s is” (knowledge) , was f i rs t coined in 1811 by an Austr ian phys ic ian named Johann Adam Schmidt . 2 Tradi t ional ly, pharmacognosy fo-cused on the study of crude drugs of natura l or ig in , encompass ing aspects such as authent icat ion and qual i ty contro l . In the modern era , pharmacognosy has expanded beyond t radi t ional techniques such as macroscopic ident i f icat ion and microscopy, and advances in molec-u lar b io logy and screening methods to ident i fy chemical const i tuents and therapeut ic targets have t rans-formed the f ie ld . 3 In recent years , new methods of drug discovery ut i l i z ing computer s imulat ion mod-els have been developed to com-plement the t radi t ional process of invest igat ing potent ia l new drugs based on ethnopharmacologica l observat ions . The concept of a “drug” has evolved over the course of hu-man h is tory, and the disc ip l ine of pharmacognosy has evolved a long wi th i t . The Engl ish word “drug” is der ived f rom the word “dry,” ref lect ing the fact that drugs or ig-ina l ly refer red to dr ied medic ina l p lants . In addit ion to p lant-based drugs, minera l and animal products have been used as drugs by many di fferent cu l tures , and a number of minera l and animal drugs were inc luded in c lass ica l herbal texts such as Dioscor ides ’ De Mater ia Medica and the Div ine Farmer ’s Class ic of Mater ia Medica (Shen Nong Ben Cao J ing) f rom China. Al -though some addit ional b io logica l mater ia ls such as mar ine organisms and large fungi have t radi t ional ly been used as medic ines for centu-r ies , modern pharmacognosy has expanded to invest igate new drugs der ived f rom microorganisms such

TRADITIONAL AND MODERN PHARMACOGNOSY:PERSPECTIVES FROM CHINESE AND WESTERN HERBAL MEDICINEby Dr. Er ic Brand, L .Ac. , PhD.

as bacter ia and fungi that were inaccess ib le to research before the modern era . A MULTIDISCIPLINARY SCIENCE Pharmacognosy has been a mul-t id isc ip l inary sc ience throughout h is tory. The importance of p lant-based medic ines has long caused pharmacognosy to be int r icate ly connected to botany. The c lose re-lat ionship of these two disc ip l ines was emphas ized in the 1917 text Handbook of Pharmacognosy w i th the statement : “Vegetable drugs are of vast ly greater importance and therefore a knowledge of bota-ny i s necessary to an understanding of pharmacognosy.” 4 Indeed, pr ior to the development of L innaean taxonomy and plant c lass i f icat ion texts known as “ f loras ,” most texts dedicated to p lant ident i f icat ion were “herbals” that a lso conta ined deta i l s on the therapeut ic act iv i t ies of p lants . 5 Today, taxonomic ident i -f icat ion of medic ina l p lants i s con-s idered to be a fundamenta l s tep in the authent icat ion of medic ina l mater ia ls . 7 In addit ion to botany, the f ie ld of chemist ry has had a major impact on t radi t ional pharmacognosy. Fol lowing the successfu l i so lat ion of morphine and other pure com-pounds at the beginning of the 19th century, the not ion of act ive const i tuents that could repl icate the effects of crude drugs at t racted t remendous at tent ion. Whi le most off ic ia l drugs l i s ted in pharmaco-poeias around the wor ld pr imar i ly cons is ted of p lant-based crude drugs unt i l the ear ly 20th century, the modern concept of “drugs” in popular Western cu l ture gradual ly began to focus on natura l or syn-thet ic act ive chemical const i tuents rather than crude natura l products . Today, chemist ry remains indis-pensable in pharmacognosy and is essent ia l for qual i ty contro l and new drug discovery. In recent years , the mult id isc ip l inary nature of mod-ern pharmacognosy has cont inued to expand with the ar r iva l of new techniques, such as the use of DNA bar-coding for authent icat ion or the use of metabolomics for assess-ing pharmacologic effects . Tradi t ional and modern pharmacog-nosy both emphas ize the authent i -cat ion of medic ina l mater ia ls and the discovery of new drugs through research into crude drugs. How-ever, as the techniques to ident i fy crude drugs and to d iscover new drugs have become more sophist i -cated, pharmacognosy has evolved

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TRADITIONAL AND MODERN PHARMACOGNOSY:PERSPECTIVES FROM CHINESE AND WESTERN HERBAL MEDICINEby Dr. Er ic Brand, L .Ac. , PhD.

to incorporate a range of d isc i -p l ines and tools that d id not ex is t dur ing the format ive era of t radi -t ional pharmacognosy. Due to the vast number of natura l substances that must be pr ior i t i zed for invest i -gat ion, t radi t ional pharmacognosy i s of ten in formed by ethnophar-macology, the t radi t ional use of medic ina l substances in indigenous cu l tures . By contrast , in modern pharmacology, the use of h igh throughput screening techniques a l lows for the rapid screening of thousands of substances in a short per iod of t ime, which expands the number of p lants that can be rap-id ly assessed. A ided by computer s imulat ions and methods of match-ing l ibrar ies of chemical s t ructures to b iochemical targets , modern pharmacognosy has expanded the poss ib i l i t ies for drug discovery, making pharmacognosy less de-pendent on researching substances wi th a cu l tura l h is tory of medic ina l use. TRADITIONAL PHARMACOGNOSY IN CHINA In China, the disc ip l ine of t radi t ion-a l pharmacognosy was in f luenced by exchange wi th Japan, where a number of new texts devoted to pharmacognosy emerged in the late 19th century. In 1905, the Chinese scholar Zhao Yuhuang studied in Japan and returned to emphas ize pharmacognosy as a professor in Bei j ing; h is Qizhou Medic ina l Journal became the f i rs t Chinese resource that organized mater ia medica knowledge based on Lat in taxonomy. 7

Whi le th is era represents a mi le-stone for the ar r iva l of t radi t ional pharmacognosy as a modern sc i -ence in China, many aspects re le-vant to t radi t ional pharmacognosy had been prev ious ly explored in Chinese bencao l i terature. For ex-ample, the Ming Dynasty i l lust rated text Or ig ins of the Mater ia Medica (Ben Cao Yuan Shi ) was dedicated to the morphologica l ident i f icat ion of medic ina l mater ia ls , and prev i -ous works such as the Extens ion of the Mater ia Medica (Ben Cao Yan Yi ) focused on the di fferent iat ion of genuine vs . inauthent ic medic ina ls . 7

In 1593 AD dur ing the Ming Dy-nasty, the Compendium of Mater ia Medica (Ben Cao Gang Mu) by L i Sh izhen was publ ished; featur ing 1 ,892 medic ina l substances, th is monumenta l text ut i l i zed a novel , two-t iered c lass i f icat ion system for organiz ing natura l substances, and remains a r ich resource wi th great re levance for t radi t ional

pharmacognosy. Addit ional ben-cao texts focused on recording medic ina l substances f rom speci f ic geographic regions, such as the Mater ia Medica of Steep Moun-ta ins ides (Lu Chan Yan Ben Cao) , which cata logued local medic ines f rom the region around modern-day Hangzhou. 7 Bencao l i terature a lso inc ludes texts dedicated to me-dic ina l process ing, a pract ice that s igni f icant ly impacts the chemist ry and therapeut ic nature of medic i -na l substances. However, a l though bencao l i terature remains a r ich resource for t radi t ional pharma-cognosy, i t s g lobal impact has long been l imited by a language barr ier because few ancient bencao texts have been t rans lated into Western languages. As can be seen f rom these exam-ples , t radi t ional bencao l i terature conta ins va luable in format ion on the authent icat ion of medic ina l mater ia ls , c lass i f icat ion of natura l substances, and acquis i t ion of new drug sources f rom the explorat ion of loca l ly used plants by indige-nous groups. Whi le these devel -opments arose h is tor ica l ly pr ior to the ar r iva l of the modern sc ience of pharmacognosy, these features nonetheless i l lust rate a sophist i -cated level of knowledge regarding the study of crude drugs. By ap-ply ing techniques such as chemical analys is , laser micro-dissect ion, genet ic test ing and taxonomy, modern pharmacognosy i s a l lowing t radi t ional Chinese medica l knowl-edge to be systemat ica l ly assessed us ing the sc ient i f ic method. Chem-ica l analys is a l lows the effects of t radi t ional process ing methods on the chemist ry of crude drugs to be studied, and the integrat ion of bencao study and modern taxono-my has led to c lar i f icat ion regard-ing the used plant species for many medic ina l mater ia ls descr ibed in anc ient texts . Whi le t radi t ional pharmacognosy techniques such as microscopy have long been essen-t ia l for determining the authent ic i ty of c rude drugs, modern techniques such as combining laser micro-dis-sect ion wi th LC-MS have advanced the disc ip l ine of microscopy by determining where act ive const i t -uents are concentrated wi th in the anatomical s t ructures of botanica l mater ia ls . This research has s ig-n i f icant impl icat ions for the qual -i ty assessment and product ion of medic ina l mater ia ls , and can a lso help to resolve cases where the t radi t ional l i terature conta ins con-f l ic t ing statements wi th regard to medic ina l qual i ty. 8

TRADITIONAL PHARMOCOGNOSY IN THE WEST As in China, the study of crude drugs in the West preceded the formal development of pharmacog-nosy as a named sc ient i f ic d isc i -p l ine. Texts dedicated to medic ina l mater ia ls were f i rs t establ ished in Europe in Greek and Roman t imes, and many loca l and fore ign me-dic ina ls were descr ibed in anc ient Western texts . In the Renaissance per iod, the ar r iva l of pr int ing technology hera lded a dramat ic increase in the number of herbal texts that were publ ished, and the l i terature began to d ivers i fy be-yond the or ig ina l foundat ions la id by Dioscor ides . Texts in European languages other than Lat in began to prol i ferate, and wi th the age of explorat ion and colonizat ion of new terr i tor ies , new herbal medic ines were int roduced to Europe. S ince the t ime of Theophrastus (a s tudent of Ar is tot le ) , there has been a c lose re lat ionship between the f ie lds of botany and Western herbal medic ine. This re lat ion-sh ip developed dramat ica l ly a f ter pr inted texts ca l led “herbals” emerged in the late 15th century, and the re lat ionship between ear ly botanica l and medic ina l l i terature i s descr ibed in deta i l in key h is tor-ica l works such as Herbals , Thei r Or ig in and Evolut ion: A Chapter in the History of Botany 1470-1670, wri t ten by Agnes Arber in 1912.(5 ) Deta i led botanica l descr ipt ions were f i rs t found in herbals , which focused on plants that were used medic ina l ly ; as the disc ip l ine of taxonomy developed, botanica l de-scr ipt ions of p lants moved beyond herbal medic ines to focus on the c lass i f icat ion of a l l p lants us ing the systemat ic approach that def ines modern taxonomy. In a s i tuat ion that para l le ls the current s tate of pharmacognosy, taxonomy i tse l f i s d iv ided into t radi t ional and modern approaches; t radi t ional taxonomy favors morphologica l ident i f ica-t ion whi le modern taxonomy is a lso in f luenced by newer analyt ica l methods such as genet ic test ing and chemotaxonomy. Beyond botanica l descr ipt ions of the source plants , t radi t ional knowledge about crude drugs in anc ient Western herbal texts of ten featured discuss ions of growing regions, harvest t imes, f lavors and propert ies , as wel l as character is -t ics of d i fferent preparat ions , such as t inctures , powders , syrups, etc . Fol lowing the invent ion of the mi-croscope, microscopy was appl ied extens ive ly in herbal authent ica-

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t ion, and numerous d iscuss ions re lated to avoiding adul terants are found in the Western herbal l i terature. In the 19th century, the disc ip l ine of medic ina l chem-is t ry advanced cons iderably, and pure compounds began to become incorporated into Western pharma-copoeia texts (which had prev ious ly only conta ined references to crude drugs and extracts ) . Fol lowing the successfu l i so lat ion of pure compounds wi th medic ina l e ff icacy, the disc ip l ine of phar-macognosy in the West gradual ly began to sh i f t i t s focus f rom eval -uat ing the qual i ty of c rude drugs based on organolept ic propert ies to ident i fy ing the act ive compo-nents wi th in crude drugs through chemical analys is . Just as the disc ip l ine of botany in i t ia l ly began wi th a focus on plants wi th me-dic ina l use in t radi t ional cu l ture and then expanded to focus on the c lass i f icat ion of a l l p lants , the f ie ld of pharmacognosy has ex-panded beyond i ts or ig ina l focus on ethnopharmacology, incorporat-ing new approaches such as h igh throughput screening to search for novel and undiscovered act ive ingredients in a progress ive ly wider range of p lants . Nonetheless , i t i s est imated that only about 6% of h igher p lants have been screened for b io logic act iv i ty, and only about 15% have been evaluated phyto-chemical ly. 9

The process of d iscover ing new medic ines and improving the qual i -ty contro l of ex is t ing crude drugs i s a monumenta l task that has occu-pied humanity s ince the dawn of wr i t ten h is tory. In the modern era , enhanced methods of screening and test ing have great ly speeded the acquis i t ion of new knowledge, but many known crude drugs re-main poor ly understood and many potent ia l new drugs are yet to be discovered. L ikewise, a t remen-dous amount of t radi t ional cu l tura l knowledge re levant to the f ie ld of pharmacognosy has been recorded around the wor ld, but only a t iny f ract ion of th is knowledge has been disseminated wor ldwide in mult ip le languages. Consequent ly, there i s a vast amount of knowledge that remains to be discovered through the appl icat ion of both t radi t ional and modern pharmacognosy, and both aspects of the f ie ld have a br ight future and l imit less hor izons.

REFERENCES

1) de Pasquale , A, Pharmacognosy: the o ldest modern sc ience, J Eth-nopharmacol . 11 (1 ) :1-16 (1984)

2 ) Heinr ich, Fundamenta ls of Phar-macognosy and Phytotherapy, E lse-v ier Heal th Sc iences, p . 19 , 2004

3) Sarker S , Pharmacognosy in mod-ern pharmacy curr icu la , Pharma-cogn Mag. 8 (30) : 91–92 (2012)

4 ) Wal l , Handbook of Pharmacogno-sy, Mosby, St . Louis , p . 15 , 1917

5) Arber, Herbals : Thei r Or ig in and Evolut ion, Cambr idge Univers i ty Press , London, 1912

6) Zhao ZZ, Hu Y, L iang ZT, Yuen J , J iang ZH, Leung K, Authent icat ion is Fundamenta l for Standardizat ion of Chinese Medic ines , P lanta Med 72(10) : 865-874 (2006)

7 ) Zhao et a l . , Chinese Medic i -na l Ident i f icat ion: An I l lust rated Approach, Paradigm Publ icat ions , Taos, New Mexico, 2014

8) Yi L , L iang ZT, Peng Y, Yao X, Chen HB, Zhao ZZ. T issue-speci f ic metabol i te prof i l ing of a lka lo ids in S inomeni i Caul is us ing laser micro-dissect ion and l iquid chromatogra-phy-quadrupole/t ime of f l ight-mass spectrometry. Journal of Chroma-tography A. , 1248: 93-103 (2012)

9 ) Fabr icant DS, Farnsworth NR. The va lue of p lants used in t radi -t ional medic ine for drug discovery. Env i ronmenta l Heal th Perspect ives , 109(1 ) :69–75 ( 2001)

TRADITIONAL AND MODERN PHARMACOGNOSY:PERSPECTIVES FROM CHINESE AND WESTERN HERBAL MEDICINE (CONT.)by Er ic Brand, L .Ac.

Er ic Brand is a Chinese medic ine pract i t ioner wi th a pass ion for mater ia medica and herbal qual i -ty d iscernment . Af ter graduat ing f rom the Pac i f ic Col lege of Or ienta l Medic ine in 2003, Er ic spent over a decade pursu ing academic and c l in ica l opportuni t ies in As ia . He earned h is PhD at the School of Chinese Medic ine at Hong Kong Bapt is t Univers i ty in the f ie ld of Chinese herbal pharmacy, and he remains engaged in teaching and research. Er ic i s the Deputy Gener-a l Manager for Bei j ing Tongrentang (USA) , and serves as a TCM advisor to the Amer ican Herbal Pharmaco-poeia . He has wr i t ten or t rans lated a var iety of modern and c lass ica l texts and peer- rev iewed art ic les , and is the founder of the granule company Legendary Herbs.

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ABSTRACT Chemotherapy- induced per iphera l neuropathy (CIPN) a ffects 30%-70% of chemotherapy pat ients , some descr ib ing i t as the most t roubl ing s ide effect . Symptoms inc lude numbness , t ingl ing and burning pain in the hands and feet . This i s a qual i tat ive systemat ic rev iew iden-t i fy ing acupuncture c l in ica l t r ia ls t reat ing CIPN. Human research wi th a contro l group f rom any geograph-ic locat ion wr i t ten in the Engl ish language were inc luded. Searches were done on PubMed, Cochrane Reviews, and ar t ic le reference l i s ts . Of the s ix s tudies inc luded, ha l f found a benef i t to acupuncture, whi le the rest found no benef i t or even increased pain . Key resul ts suggest avoiding e lectroacupunc-ture dur ing chemotherapy. Im-provements were found in s tudies us ing aur icu lar acupuncture, and object ive nerve conduct ion ve loc i ty measurements . Smal l sample s izes and mixed resul ts warrant fur ther research before making def in i -t ive t reatment recommendat ions . Standardized point se lect ion and measurement sca les would help to compare groups. Western medi-c ine has few effect ive t reatments , making acupuncture an at t ract ive a l ternat ive.

INTRODUCTION

Background on Cancer from a Western Medical Perspect ive

“Cancer i s a group of d iseases character ized by the growth and spread of abnormal ce l l s . I f the spread is not contro l led, i t can re-su l t in death.” 1 The cause of many cancers i s unknown. However, many types of cancer can be caused by l i festy le choices such as smoking tobacco or being overweight . 1 On the other hand, some cancers are caused by genet ic mutat ions , hor-mones and immune condit ions . 1

In the U.S. , an est imated 1 .68 mi l -l ion new cancer cases were expect-ed to be diagnosed in 2016. 1 In the U.S. , approximately 41 out of 100 men and 38 out of 100 women wi l l develop cancer dur ing thei r l i fet ime. 2 In the U.S. , near ly 14 .5 mi l l ion people were l iv ing beyond a cancer d iagnosis in 2014, and th is number i s expected to r i se to a lmost 19 mi l l ion by 2024. 2

The economic impact of th is d is -ease is a lso s tagger ing. In 2014, U.S . tota l cancer expenses tota led $87.8 b i l l ion according to the Medica l Expenditure Panel Survey (MEPS) . 3

Background on Chemotherapy and Chemotherapy- Induced Per ipheral Neuropathy

Some studies report an inc idence as h igh as 70% of pat ients exper i -ence CIPN, but others report 30% to 40%. 4 CIPN negat ive ly a ffects a pat ient ’s qual i ty of l i fe . CIPN was reported by one-th i rd of pat ients as thei r most t roubl ing cancer- re lated s ide-effect .” 4 I t may a lso requi re chemotherapy dose reduct ion or cessat ion resul t ing in a h igher morbidi ty and morta l i ty. 5 CIPN may pers is t or even intens i fy long af ter chemotherapy t reatments are completed. 6 CIPN adds an average of $17,344 in heal thcare costs per pat ient per year compared to those wi thout these symptoms. 7

The per iphera l nervous system is most suscept ib le to the damaging effects of cytotox ic and bio logic agents used to t reat cancer. “The chemotherapy agents most com-monly caus ing neuropathy are taxane (pac l i taxel , docetaxel ) , v inca a lka lo ids (v incr is t ine) , p lat inum compounds (c isp lat in , carboplat in ) , proteasome inhib i tors (bortezo-mib) , and ant iangiogenic com-pounds ( tha l idomide) .” 4 The most common symptoms of CIPN inc lude painfu l paresthes ia in the hands and feet , a l lodynia , numbness , and cold hypersens i t iv i ty. 4

Western medic ine poor ly under-stands the pathophys io logy of CIPN, and as a resul t , t reatments to prevent i t are inadequate. 5 CIPN neurotoxic i ty involves DNA damage, mitochondr ia l tox ic i ty, ox idat ive s t ress , and ion chan-nel remodel ing which can lead to apoptos is (ce l l death) in the pe-r iphera l nervous system neurons. 8 Once CIPN is establ ished, Western t reatment opt ions are a lso l imited. 5

As a resul t , there i s an urgent need for complementary and a l ternat ive medic ine. 9

Background on Cancer from a Tradit ional Chinese Medic ine Perspect ive

Dur ing the 16th to the 11th centu-ry B.C. , inscr ipt ions on bones and torto ise shel ls ment ioned the word l iu or tumor. 10 According to the Zhen Z i Tong 10 and Shuo Wen J ie Z i d ict ionar ies , 10 the word zhong (swel l ing) was a type of abscess , where l iu meant “to f low.” When combined, zhong l iu meant swol-len tumor or neoplasm. 10 In a book ca l led the Zhou L i compi led in the Qin dynasty (221-207 B.C. ) , doctors t reated a mal ignant swol len sore wi thout u lcerat ion 10 – very s imi lar

USING ACUPUNCTURE TO TREAT CHEMOTHERAPY-INDUCED PERIPHERAL NEUROPATHYby Heidi Bart let t , L .Ac.

to tumors of the breast , head or neck that we see now. The theory i s a tumor develops when there i s t i ssue prol i ferat ion due to q i and blood accumulat ion. 10

Cancer can occur due to severa l factors such as invas ion of exter-na l pathogens, inappropr iate d iet , emot ions , and a combinat ion of phlegm with q i and blood stag-nat ion. 10 A lso, “def ic iency and deplet ion of the zang fu organs i s an inev i table outcome of var ious pathologica l factors and at the same t ime is a prerequis i te for the development of cancer.” 10

Background on Per ipheral Neuropathy from a Tradit ional Chinese Medic ine Perspect ive

As chemotherapy was not pract iced in anc ient China, the only way to f ind TCM treatments for CIPN is to look at the condit ion’s symptoms. Examples inc lude re lat ing i t to wei zheng or wi l t ing condit ion; ma mu as the exper ience of numbness and t ingl ing; and bu ren descr ib ing in-sens i t iv i ty or lack of feel ing. 11

METHOD

The purpose of th is s tudy is to determine whether acupuncture i s an effect ive t reatment for CIPN. This i s a qual i tat ive systemat ic rev iew inc luding human c l in ica l t r ia ls wi th a contro l group wr i t ten in Engl ish . Because there i s less research ava i lable for acupuncture, there wi l l be no l imit to s tudy inc lu-s ion based on publ ish ing date. In contrast , research regarding CIPN mechanisms and inc idence wi l l be l imited to reports publ ished af ter 2013 because af ter 5 years , system-at ic rev iews become out of date due to new ev idence of therapeut ic effect iveness . 12 Outcomes ident i fy how acupuncture affects CIPN pain , numbness and t ingl ing by measur-ing pain , qual i ty of l i fe , and nerve conduct ion ve loc i t ies . Research t r ia l ar t ic les wi l l be searched by the pr imary author on PubMed and the Cochrane Reviews database us ing the fo l lowing search terms: acu-puncture, Tradi t ional Chinese Medi-c ine, TCM, a l ternat ive medic ine, neuropathy, CIPN (chemothera-py- induced per iphera l neuropathy) , and chemotherapy.

Exc luded research cons is ts of case studies , protocols wi thout resul ts , ar t ic les , surveys , and unpubl ished data , as wel l as research on TENS ( t ranscutaneous nerve st imulat ion) , v i tamins , supplements , and herbs . Acupuncture t r ia ls wi th bee venom in ject ions wi l l be exc luded, as us-

8

ing hypodermic needles are outs ide the Cal i forn ia acupuncture scope of pract ice. 13 Research studies on neuropathy due to d iabetes , autoimmune disorders , genet ic d isorders , human immunodef ic ien-cy v i rus (HIV) , or t rauma wi l l be exc luded as they have a d i fferent pathogenes is f rom CIPN.

RESULTS

Background on CIPN Sever ity Measurements

Compar ing studies i s d i ff icu l t , s ince there does not seem to be a cons is -tent s tandard sca le to measure the stage and sever i ty of CIPN. Gener-a l ly, three di fferent ways were used to determine improvement : pa in , qual i ty of l i fe , and nerve conduc-t ion ve loc i t ies .

F i rs t , there were severa l sca les used to measure pain wi th in these studies . The most common was the VAS (v isua l analogue sca le ) , 14 measur ing a pat ient ’s subject ive exper ience of pain ut i l i z ing a quest ionnai re about pain intens i -ty. These studies genera l ly used a numer ica l sca le f rom 0 to 100 wi th a lower number indicat ing less pain , and a h igher number indicat ing more intense pain . In th is rev iew, the NRS (numer ica l rat ing sca le ) measures pain s imi lar ly to the VAS, but wi th a sca le of 0 to 10. The neuropathic pain sca le (NPS) i s a lso a subject ive pat ient quest ionnai re cons is t ing of 10 i tems des igned to speci f ica l ly address neuropath-ic pain such as react ion to l ight touch, t iming, intens i ty, and qual i ty of the pain . 15-16 Another subject ive pat ient quest ionnai re des igned to eva luate cancer pain , i s the Br ief Pa in Inventory – Short Form (BSF-

SF) , in which pain i s rated on a sca le of 0 to 10. I t cons is ts of n ine quest ions assess ing pain sever i ty and i ts impact on dai ly funct ions . 17 A l though or ig ina l ly des igned to eva luate d iabet ic neuropathy, the TNS (Tota l Neuropathy Score) i s now a lso used to eva luate CIPN pain . 18-19 In addit ion to the pat ient ’s subject ive report , th is sca le a lso in-c ludes object ive measures such as p in pr ick , v ibrat ion threshold and nerve conduct ion studies . The TNSc is a vers ion of the TNS sca le de-s igned to measure only the c l in ica l s igns and symptoms of CIPN. 18-19

There were severa l sca les used to measure changes in qual i ty of l i fe . The FACT-GOG-Ntx (Funct ional As-sessment of Cancer Therapy/Gyne-cologic Oncology Group/Neurotox-ic i ty quest ionnai re ) was used most of ten. A predecessor quest ionnai re was the FACT-G (Funct ional Assess-ment of Cancer Therapy – Genera l ) , developed to ident i fy a cancer sur-v ivor ’s qual i ty of l i fe . This sca le i s a subject ive pat ient quest ionnai re wi th 28 i tems ident i fy ing the state of i l lness and phys ica l capabi l i -t ies , as wel l as the pat ient ’s soc ia l and emot ional s tate . 20 Bui ld ing on th is prev ious sca le , the FACT/GOG-Ntx 19,21 was developed for women diagnosed wi th gynecologic mal ignancies who were t reated wi th neurotoxic drugs such as taxanes and plat inum. These pat ients com-

pla ined of CIPN, making th is more speci f ic sca le appropr iate for the inc luded research studies . Another var iat ion of th is quest ionnai re i s the FACT-Taxane wi th addit ional i tems speci f ic to taxane such as ar thra lg ias , myalgias , and sk in d is -colorat ion. 19

The U.S. Department of Heal th and Human Serv ices , Nat ional Inst i -tutes of Heal th , Nat ional Cancer Inst i tute 22 dev ised yet another way to measure t reatment s ide effects . Or ig ina l ly ca l led the Common Tox-ic i ty Cr i ter ia (CTC) , i t i s now known as the Common Terminology Cr i te-r ia of Adverse Events (CTCAE) . The Nat ional Cancer Inst i tute def ines an adverse event (AE) as any s ide effect due to the medica l t reatment rather than the disease. This sca le measures the AE as a grade 1 to 5 , where grade 1 i s cons idered mi ld, and grade 5 resul ts in death.

The f ina l qual i ty of l i fe cr i ter ia developed by the European Organi -zat ion for Research and Treatment of Cancer i s the Qual i ty of L i fe Quest ionnai re (EORTC-QLQ-C30) . This model measures the pat ient ’s funct ional i ty – phys ica l , ro le , cogni t ive , emot ional and soc ia l . I t a lso measures symptoms such as fa-t igue, pain , nausea, and vomit ing. F ina l ly, i t has a sca le to eva luate the pat ient ’s overa l l heal th and qual i ty of l i fe . 23 I t too, has supple-

9

ments to make i t more speci f ic to the disease being measured, such as the QLQ-CIPN20 24 adding ques-t ions speci f ic to CIPN. S imi lar ly, the QLQ-OV 28, des igned for wom-en diagnosed wi th ovar ian cancer, adds sca les regarding the pat ient ’s body image, sexual i ty, at t i tude to the disease or t reatment , as wel l as other chemotherapy-re lated s ide effects l ike per iphera l neuropathy, hormonal compla ints , and digest ive i ssues . 25-26

The th i rd type of CIPN evaluat ion re lated to nerve conduct ion ve loc-i t ies (NCV) to ident i fy any abnor-

mal i t ies in mixed, motor or sensory nerves by e lect r ica l ly s t imulat ing nerves wi th smal l safe pulses over the l imbs and then measur ing the resul ts . 27 W ith in the category of NCV, two types of nerve ve loc i t ies are measured – motor nerve con-duct ion ve loc i ty (MCV) and sensory nerve conduct ion ve loc i ty (SCV) as a way to gauge CIPN sever i ty.

REVIEW OF THE RESEARCH

After screening t i t les and/or ab-st racts , 14 ar t ic les were exc luded for the fo l lowing reasons: the focus was on an intervent ion other than

USING ACUPUNCTURE TO TREAT CHEMOTHERAPY-INDUCED PERIPHERAL NEUROPATHY (CONT.)by Heidi Bart let t , L .Ac.

acupuncture, the neuropathy was not re lated to chemotherapy, the acupuncture t reatment p lan inc luded in ject ing pharmaceut ica l der ivat ives into acupuncture points , the pat ients were not human, the study was not wr i t ten in Engl ish , there were dupl icated studies , the study did not have a contro l group, or they were not re levant . Af ter deta i led evaluat ion, 6 s tudies were inc luded in the rev iew for t reat ing CIPN with acupuncture. For an a l -phabet ica l summary of the c l in ica l s tudies see Table 2 .

Overa l l , there were few studies to rev iew, t reat ing a fa i r ly smal l num-ber of pat ients dur ing a re lat ive ly short per iod of t ime. This makes i t d i ff icu l t to genera l i ze resul ts to the overa l l CIPN pat ient popula-t ion. Also, per iphera l nerves take a long t ime to grow af ter in jury, growing only 2 mm to 4 mm per day. 28 Therefore, a longer t reat-ment window may be necessary to rea l i ze resul ts . For overa l l resu l ts of acupuncture t reat ing CIPN, some studies found no di fference be-tween the contro l and acupuncture, some found the pain increased,

whi le others noted a decrease in pain and improved nerve con-duct ion ve loc i t ies . Of note, two studies us ing e lectroacupuncture (EA) dur ing chemotherapy in fus ions found the t reatment increased CIPN pain , suggest ing EA may not be benef ic ia l dur ing chemothera-py. Out of the s ix s tudies inc luded, two took place whi le pat ients were st i l l receiv ing chemotherapy, whi le the remain ing four took place af ter pat ients were complete ly f in ished wi th chemotherapy

Alemi et a l . (2003)

A study by Alemi , Rubin, P ich-ard-Leandr i , Fermand-Brule , Du-breui l -Lemaire and Hi l l 29 eva luated aur icu lar acupuncture compared to sham aur icu lar acupuncture, as wel l as a contro l group receiv ing ear seeds. The goal for hav ing two sep-arate contro l groups was to ident i fy whether insert ing needles at inva l id acupuncture points was a va l id con-t ro l . Th is s tudy randomly ass igned 90 pat ients into three groups. For the acupuncture groups, s ta in less s teel needles were implanted into

10

the ear, and the pat ients were inst ructed to record when the needles fe l l o ff . They received a t reatment once a month for three months . An e lectronic vol tmeter was used to f ind ear points e l ic i t ing an e lectr ic response. The two con-t ro l groups received t reatments at p lacebo points – one group receiv-ing needles , the other receiv ing ear seeds. Overa l l , th is s tudy adhered c losely to STRICTA guidel ines , wi th the except ion of ident i fy ing the acupunctur is t qual i f icat ions . This last i tem may not be as re levant , s ince the points were determined by e lect r ica l response. After 60 days , 79 pat ients completed the t r ia l , w i th the acupuncture group demonstrated improvements wi th a decrease in VAS pain scores . Contrary to expectat ions , the two placebo groups had no effect as a resul t of thei r t reatments .

Greenlee, et a l . (2016)

The study by Greenlee and col -leagues 30 researched whether acupuncture could prevent CIPN in breast cancer pat ients undergoing taxane chemotherapy. This s tudy inc luded 63 women who received 12 weekly t reatments and were randomly ass igned to two groups – e i ther e lect roacupuncture or sham electroacupuncture as the contro l . The e lectroacupuncture group received 2 Hz t reatments based on a Tradi t ional Chinese Medic ine (TCM) diagnosis of q i and blood def ic iency and stagnat ion. The sham acupuncture group received t reatment us ing Park Sham col laps-ib le needles which touched but d id not penetrate the sk in . 31 Whi le the des ign of the study c losely match-es STRICTA guidel ines , the short amount of t ime pat ients received t reatment may hamper pos i t ive resul ts . The outcome measures in-c luded the BSF-SF, FACT/GOG-Ntx, FACT-Taxane, and NPS sca les . Ac-cording to the BSF-SF evaluat ions , at 16 weeks , the sham acupuncture group pain sca les reverted to thei r basel ine level , whi le the e lec-t roacupuncture group’s pain was actual ly gett ing worse, suggest ing that pat ients should not receive EA whi le gett ing chemotherapy t reat-ment for taxane. The other sca les showed no measurable d i fference between the two groups.

Han et a l . (2017)

A study conducted by Han and col -leagues 32 examined the use of acu-puncture and methy lcobalamin to t reat bortezomib- induced per iph-era l neuropathy (B IPN) . This s tudy did not inc lude in ject ions into acu-

puncture points so i t was inc luded in the rev iew. This research studied 104 mult ip le myeloma pat ients who had completed chemotherapy. Over 84 days , pat ients received a tota l of 10 acupuncture t reatments . The cyc le began wi th t reatments dai ly for three days , then every other day for 10 days , then th is t reatment cyc le repeated af ter 28 days for three cyc les . In conjunct ion wi th the acupuncture t reatment , pa-t ients received 500 μg methy lcobal -amin in ject ions every other day for 20 days , fo l lowed by two months of ora l methy lcobalamin three t imes a day. The contro l group received the same methy lcobalamin regimen wi thout acupuncture. Methy lco-balamin, an act ive form of V i tamin B12, i s thought to improve nerve conduct ion and promote regen-erat ion of in jured nerves . 33 The report c losely adhered to STRICTA guidel ines , but needed to d iscuss the TCM diagnosis , type of nee-dles used, and whether the needles were st imulated af ter insert ion. Af ter t reatment , the acupuncture p lus methy lcobalamin group expe-r ienced s igni f icant improvements in pain rea l i z ing an 85.7% reduct ion in VAS pain scores compared a pain reduct ion of 77 .6% in the contro l group. F ina l ly, the report appears to contradict i t se l f on the MCV va l -ues – say ing there was no change in the acupuncture group, then later report ing there was a s igni f icant change.

Lu et a l . (2012)

The next p i lot s tudy by Lu and col leagues 34 examined how acu-puncture affects qual i ty of l i fe for women with ovar ian cancer. The t r ia l t reated a tota l of 21 pat ients at two cancer centers who were re-ceiv ing chemotherapy at the t ime. Pat ients received a tota l of 10 acu-puncture t reatments two to three t imes a week over a tota l of 21 days . The act ive acupuncture group was t reated wi th needles at a depth of 10 mm on recognized acupunc-ture points , as wel l as 25 Hz EA on at least two points on the pat ient ’s legs . In contrast , the contro l group received needles that d id not cor-respond to acupuncture points , and were needled to a depth less than 0 .2mm. This s tudy c losely fo l lowed STRICTA guidel ines , except i t d id not ment ion the acupunctur is t qual i f icat ions . The outcomes were measured us ing EORTC-QLQ-C30 and EORTC-QLQ-OV28. The pa-t ient ’s neuropathy was measured 30 minutes af ter t reatment , so any t ingl ing, or numbness increase fe l t at that t ime could have been part of the t reatment rather than a t rue

increase in neuropathy. Also, in Japanese acupuncture, the t reat-ment depths are very shal low, so there i s a chance the contro l group received some benef i t f rom the t reatment . In addit ion, the short t reatment length could have in f lu-enced the resul ts . At the end of the study, there were no s igni f icant CIPN di fferences between the sham and acupuncture groups.

Rostock et a l . (2013)

Rostock, Jaros lawsk i , Guethl in , Ludtke, Schröder, and Bartsch 35 conducted a four-arm randomized t r ia l eva luat ing EA’s effect iveness to t reat CIPN. In Germany, where i t was conducted, hydroelectr ic baths and v i tamin B supplements are used to t reat neuropathy. The study randomly ass igned 60 pa-t ients who had completed chemo-therapy into four t reatment groups: EA, hydroelectr ic baths , v i tamin B complex, and placebo. Pat ients in the EA group received a tota l of seven to n ine tota l t reatments over a three-week per iod. The hydro-e lectr ic bath group dipped e i ther thei r arms or legs , depending on which l imbs had CIPN, up past the e lbow or knee jo int respect ive ly for 15 minutes wi th a current of 50 Hz in the water. In the v i tamin B protocol , pat ients ingested three h igh dosage capsules , conta in ing 100 mg of th iamine n i t rate and 100 mg of pyr idoxine hydrochlo-r ide, each day for three weeks . The placebo group fo l lowed the same regimen, but ingested capsules conta in ing lactose. There were some l imitat ions to th is s tudy. From a STRICTA perspect ive, i t was miss ing the TCM rat ionale for t reatment , needles used, and the needle depth. The outcome was measured us ing the NRS pain sca le , and the NCI-CTC sca le but found no s igni f icant d i fference between the t reatment groups. The authors noted the pat ient ’s pa in scores for a l l groups were low at the begin-n ing of the study, leav ing l i t t le room for improvement . Pat ients a lso received other t reatments such as sport therapy, phys iotherapy and massage at the same t ime which could be part of the reason place-bo groups did so wel l . The placebo group may have a lso fared better because 88% star ted the study wi th paresthes ia – compared to 100% of the EA group. Al though not men-t ioned in the study, the e lectr ic current in the hydroelectr ic bath could have a s imi lar effect to EA.

Schroeder et a l . (2012)

Schroeder, Meyer-Hamme, and

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Epplée 36 publ ished a p i lot s tudy invest igat ing whether acupunc-ture could improve NCV for CIPN pat ients . This s tudy inc luded a tota l of 11 pat ients , wi th a se l f -se-lected contro l group who refused acupuncture. Pat ients in the acu-puncture group received a tota l of 10 t reatments over the course of three months . The research c losely adhered to STRICTA guidel ines , except omit t ing the brand of nee-dle used. In addit ion, the groups were not randomly ass igned, but instead se l f -se lect ing. Outcomes were measured by NCV, wi th the acupuncture group demonstrat ing improvement af ter fo l low-up at s ix months post- t reatment , suggest ing that acupuncture has a pos i t ive effect on CIPN. The length of t ime for fo l low-up is a s t rength of th is s tudy compared to the others in th is rev iew, g iven the t ime i t takes for nerves to regenerate.

DISCUSSION

After rev iewing the s ix inc luded studies , i t i s d i ff icu l t to make broad genera l i zat ions about the out-comes. Three studies showed im-provement af ter acupuncture (Al imi et a l . , 29 Han et a l . , 32 and Schroeder et a l . 36) , whi le three showed e i ther no di fference f rom the contro l group, or increased pain (Greenlee et a l . , 30 Lu et a l . , 34 and Rostock et a l . 35) . Genera l i z ing the resul ts i s a lso hampered by the smal l sam-ple s izes in each of these studies . Another chal lenging part of eva lu-at ing these studies overa l l i s that the pat ient populat ion is heteroge-neous – some were t reated dur ing chemotherapy, whi le others only a f ter chemotherapy was completed. Future research should a lso cons id-er s tudies over a longer per iod of t ime due to the t ime i t takes nerves to regenerate.

Each study used a d i fferent point prescr ipt ion, and only one study, by Greenlee et a l . , 30 ment ioned a TCM diagnosis or rat ionale for why the points chosen. Whi le a d iagnosis of q i and blood stagnat ion a long wi th some def ic iency might be st ra ight-forward in these cases , the organ affected by cancer may change the t reatment protocol . This makes i t d i ff icu l t to determine an opt imal point prescr ipt ion to t reat CIPN.

In addit ion, each study used a d i fferent sca le to measure the outcome, making i t d i ff icu l t to do di rect outcome compar isons, espe-c ia l ly s ince the sca les are largely subject ive. The most promis ing studies had an object ive way to choose the acupuncture points ,

such as Al imi et a l . 29 us ing the e lec-t ronic vol tmeter to se lect aur icu lar points , or Schroeder et a l . 36 and Han et a l . 32 choosing NCV as an object ive outcome measurement . I t would be interest ing to do a me-ta-analys is of the NCV studies .

For the studies ut i l i z ing EA, none descr ibed thei r reasoning for the Hz sett ing or the t reatment length of t ime. For instance, Greenlee et a l . 30 used 2 Hz for 30 minutes , Lu et a l . 34 used 20-25 Hz for 30 minutes , and Rostock et a l . 35 used 50 Hz for 15 minutes . Research shows that enkephal in , endorphin, and endo-morphin are re leased wi th EA of 2 Hz, whi le dynorphin i s re leased wi th a f requency of 100 Hz. 37 These four pept ides are an essent ia l way that EA mediates pain in the cen-t ra l nervous system. 37 By combining the 2 Hz and 100 Hz f requencies , a l l four neuropept ides are re leased in order to prov ide the greatest short - term therapeut ic effect to re-duce pain . 37 S i lva , S i lva , and Prado suggest 100 Hz EA may be helpfu l in prevent ing pain , whi le 2 Hz does not . 38 Therefore, future s tudies of EA may want to invest igate 100 Hz EA to prevent CIPN, whi le a l ternat-ing 2 Hz and 100 Hz EA for ex is t ing CIPN. In addit ion, sess ions should st r ive to be at least 20 minutes , because the “analges ic effect of acupuncture has a s low onset , and reaches a peak af ter 20 minutes .” 39

A lso, any future s tudies should take care to administer a qual i ty of l i fe or pain quest ionnai re pr ior to each indiv idual EA t reatment , s ince the v ibrat ion and t reatment i tse l f could temporar i ly increase pain and affect resul ts . Keeping in mind the l imitat ions of the ava i lable research, the data suggests avoid-ing EA whi le the pat ient i s current ly receiv ing chemotherapy t reatment , s ince two studies (Greenlee et a l . , 30 and Lu et a l . 34) ment ioned i t potent ia l ly increased pain . I t would a lso be interest ing to research the appropr iate est im f requency for nerve regenerat ion.

Based on three of the studies , there i s ev idence that acupuncture can help improve CIPN pain . Theoret i -ca l ly, the study by Al imi et a l . 29 had pos i t ive resul ts because t reatments lasted longer s ince sta in less s teel needles were reta ined in the ear, in addit ion to customized t reatments for each pat ient . One other inter-est ing resul t , the two studies (Han et a l . , 32 and Schroeder et a l . 36) us-ing object ive measurements of NCV both demonstrated improvements as a resul t of the acupuncture inter-vent ion. Nerve conduct ion studies are the standard to measure CIPN

USING ACUPUNCTURE TO TREAT CHEMOTHERAPY-INDUCED PERIPHERAL NEUROPATHY (CONT.)by Heidi Bart let t , L .Ac.

by typica l ly showing a decreased ampl i tude in sensory nerve act ion potent ia ls . 4 However, Stubblef ie ld and col leagues argue that nerve conduct ion studies corre late poor ly wi th subject ive pat ient reports and produce incons is tent f indings, but they do note that pat ients tend to underreport thei r symptoms. 19 In contrast , the other s tudies used largely subject ive measurements to determine outcomes that may affect the abi l i ty to def in i t ive ly determine resul ts . Cavalet t i et a l . , 40 and Brewer et a l . , 41 in separate research papers , noted pat ient-de-r ived quest ionnai res and phys i -c ian-based grading sca les suffer f rom subject iv i ty and incons is tency.

Because there i s l i t t le Western medic ine can offer for pain re l ie f or prevent ion of CIPN, and there has been some ev idence acupuncture can benef i t these pat ients , there i s a case to cons ider acupuncture for th is condit ion. In addit ion, acu-puncture done by t ra ined pract i -t ioners i s genera l ly a safe proce-dure, and the number of adverse events re lat ing to i t i s below that of common medica l t reatments . 42-43

CONCLUSION

These studies demonstrated mixed resul ts , h ighl ight ing a great need for addit ional research to deter-mine whether acupuncture has a benef i t in t reat ing CIPN. Based on these few studies , acupuncture may prov ide a benef i t in improving NCV, and aur icu lar acupuncture appears to be benef ic ia l . However, i t appears EA should be avoided whi le the pat ient i s current ly under-going chemotherapy. New research should inc lude large, mult i -s i te t r ia ls wi th a def ined protocol . From a Western medic ine perspect ive, more research needs to be done to ident i fy the cause of per ipher-a l neuropathy and work towards a g lobal measurement sca le so outcomes f rom research t r ia ls can be more eas i ly compared wi th more def in i t ive conclus ions . F ina l ly, because Western medic ine lacks effect ive t reatments , the low r isk of acupuncture t reatments , and some ev idence point ing to i ts abi l i ty to improve nerve conduct ion ve loc i ty, acupuncture should be cons idered as a complementary t reatment for pat ients exper ienc ing CIPN.

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13 ) Cal i forn ia Acupuncture Board, Department of Consumer Affa i rs , State of Cal i forn ia . Laws and reg-ulat ions re lat ing to the pract ice of acupuncture. Accessed: November 25, 2017. ht tp://www.acupuncture.ca .gov/pubs_forms/ laws_regs/ laws_and_regs.pdf .

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17) Cleeland CS. The br ief pa in inventory user guide. Houston, TX: Univers i ty of Texas M. D. Ander-son Cancer Center ; 1991. ht tps : //www.mdanderson.org/content/dam/mdanderson/documents/Departments-and-Div is ions/Symp-tom-Research/BPI_UserGuide.pdf . Accessed November 25, 2017.

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19) Curc io KR. Inst ruments for assess ing chemotherapy- induced per iphera l neuropathy: A rev iew of the l i terature. Cl in ica l Journal of Oncology Nurs ing. 2016;20:144–151.

20) Cel la DF, Tulsky DS, Gray G, et a l . The Funct ional Assessment of Cancer Therapy Scale : Develop-ment and va l idat ion of the genera l measure. Journal of Cl in ica l Oncol -ogy: Off ic ia l Journal of the Amer-ican Society of Cl in ica l Oncology. 1993;11:570–579.

21) Huang HQ, Brady MF, Cel la D, F leming G. Val idat ion and reduc-t ion of FACT/GOG-Ntx subscale for p lat inum/pacl i taxel - induced neu-ro logic symptoms: A gynecologic oncology group study. Internat ional Journal of Gynecologica l Cancer : Off ic ia l Journal of the Internat ion-a l Gynecologica l Cancer Society. 2007;17:387–393.

22) U.S . Department of Heal th and

Human Serv ices , Nat ional Inst i tutes of Heal th , Nat ional Cancer Inst i -tute . Common terminology cr i ter ia for adverse events (CTCAE) 4 .0 . ht tps ://evs .nc i .n ih .gov/f tp1/CTCAE/CTCAE_4.03_2010-06-14_QuickRef-erence_5x7.pdf . Accessed: Novem-ber 25, 2017.

23 ) Aaronson NK, Ahmedzai S , Bergman B, et a l . The European Organizat ion for Research and Treatment of Cancer QLQ-C30: a qual i ty -of - l i fe inst rument for use in internat ional c l in ica l t r ia ls in oncol -ogy. Journal of the Nat ional Cancer Inst i tute . 1993;85:365–376.

24) Postma TJ, Aaronson NK, Hei -mans JJ , et a l . The development of an EORTC qual i ty of l i fe quest ion-nai re to assess chemotherapy- in-duced per iphera l neuropathy: The QLQ-CIPN20. European Journal of Cancer. 2005;41:1135–1139.

25) Cul l A, Howat S , Greimel E , et a l . Development of a European Or-ganizat ion for Research and Treat-ment of Cancer quest ionnai re mod-ule to assess the qual i ty of l i fe of ovar ian cancer pat ients in c l in ica l t r ia ls : A progress report . European Journal of Cancer. 2001;37:47–53.

26) Greimel E , Bottomley A, Cul l A, et a l . An internat ional f ie ld s tudy of the re l iabi l i ty and va l id i ty of a d is -ease-speci f ic quest ionnai re mod-ule ( the QLQ-OV28) in assess ing the qual i ty of l i fe of pat ients wi th ovar ian cancer. European Journal of Cancer. 2003;39:1402–1408.

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28) Hoffman-Kim D, Mitchel JA, Bel lamkonda RV. Topography, ce l l response, and nerve regenerat ion. Annual Rev iew of B iomedica l Engi -neer ing. 2010;12:203-231.

29) Al imi D, Rubino C, P ich-ard-Léandr i E , Fermand-Brulé S , Dubreui l -Lemaire ML, Hi l l C. Anal -ges ic effect of aur icu lar acupunc-ture for cancer pain : A randomized, b l inded, contro l led t r ia l . Journal of Cl in ica l Oncology: Off ic ia l Journal of the Amer ican Society of Cl in ica l Oncology. 2003;21:4120–4126.

30) Greenlee H, Crew KD, Cap-odice J , et a l . Randomized sh-am-contro l led pi lot t r ia l of weekly e lect ro-acupuncture for the pre-vent ion of taxane- induced per iph-era l neuropathy in women with ear ly s tage breast cancer. Breast Cancer Research and Treatment . 2016;156:453–464.

31) Park J , White A, Lee H, Ernst E . Development of a new sham needle. Acupuncture in Medic ine: Journal of the Br i t i sh Medica l Acu-puncture Society. 1999:17,110-112.

32 ) Han X, Wang L , Shi H, et a l . Acupuncture combined wi th meth-y lcobalamin for the t reatment of chemotherapy- induced per iph-

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era l neuropathy in pat ients wi th mult ip le myeloma. BMC Cancer. 2017;17:40. doi :10 .1186/12885-016-3037-z .

33) Zhang M, Han W, Hu S, Xu H. (2013) . Methy lcobalamin: A potent ia l v i tamin of pain k i l ler. Neura l P last ic i ty. 2013;1-6 . doi : 10 .1155/2013/424651.

34) Lu W, Matulonis UA, Dunn JE, et a l . The feas ib i l i ty and effects of acupuncture on qual i ty of l i fe scores dur ing chemotherapy in ovar ian cancer : Resul ts f rom a p i lot , randomized sham-con-t ro l led t r ia l . Medica l Acupuncture. 2012;24(4 ) :233–240.

35) Rostock M, Jaros lawsk i K , Guethl in C, Ludtke R, Schröder S , Bartsch HH. Chemotherapy- induced per iphera l neuropathy in cancer pa-t ients : A four-arm randomized t r ia l on the effect iveness of e lect roacu-puncture. Ev idence-Based Comple-mentary and Al ternat ive Medic ine. 2013:1-9 . doi : 10 .1155/2013/349653.

36) Schroeder S , Meyer-Hamme G, Epplée S . Acupuncture for che-motherapy- induced per iphera l neuropathy (CIPN) : A pi lot s tudy us ing neurography. Acupuncture in Medic ine: Journal of the Br i t -i sh Medica l Acupuncture Society. 2012;30(1 ) :4–7.

37) Han, J . S . Acupuncture and endorphins . Neurosc ience Letters . 2004 May 6 ;361(1-3 ) :258-261. doi : 10 .1016/ j .neulet .2003.12.019.

38) S i lva ML, S i lva JRT, Prado WA. 100-Hz e lectroacupuncture but not 1-Hz e lecroacupuncture i s preemp-t ive against post inc is ion pain in rats . Journal of Acupuncture and Mer id ian Studies . 2016;9 (4 ) :200-206. doi : 10 .1016/ j . jams.201.04.006.

39) White A, Cummings M, F i l sh ie J . (2008) . An int roduct ion to west-ern medica l acupuncture. Univers i ty of P lymouth, UK: Churchi l l L iv ing-ston; 2003:41.

40) Cavalet t i G, Fr igeni B, Lanzani F, et a l . Chemotherapy- induced pe-r iphera l neurotoxic i ty assessment : A cr i t ica l rev is ion of the current ly ava i lable tools . Eur J Cancer. 2010 Feb;46(3 ) :479-94.

41) Brewer JR, Morr ison G, Dolan ME, F leming GF. Chemotherapy- in-duced per iphera l neuropathy: Cur-rent s tatus and progress . Gynecol . Oncol . 2016;140(1 ) :176-183.

42) Ernst E , White AR. Prospect ive s tudies of the safety of acupunc-ture: A systemic rev iew. Am J Med. 2001;110(6 ) (Apr i l 15 ) :481-485.

43) Lao L , Hami l ton GR, Fu J , Ber-

USING ACUPUNCTURE TO TREAT CHEMOTHERAPY-INDUCED PERIPHERAL NEUROPATHY (CONT.)by Heidi Bart let t , L .Ac.

man BM. Is acupuncture safe? A systemat ic rev iew of case reports . A l tern Ther Heal th Med. 2003;9 (1 ) (February ) :72-83.

Heidi Bart let t , L .Ac. , a F ive Branch-es Univers i ty doctora l fe l low, graduated f rom the Acupuncture and Integrat ive Medic ine Col lege, Berkeley, and is an integrat ive med-ic ine intern at Highland Hospi ta l in Oakland, CA.

NEUROPUNCTURE: SOLIDIFYING ACUPUNCTURE’S AUTHENTICITY by Michael Corradino, DAOM, MTOM, L .Ac

Acupuncture i s an anc ient medica l t reatment that dates back c lose to 2 ,500-3 ,000 years . I t i s one of the o ldest , cons is tent ly pract iced, medica l techniques in the wor ld to date. To c lear ly understand those t ime f rames I l ike to corre late 2 ,500 years ago, or about 500 BC, to more fami l iar h is tor ica l events for c lear reference. The bi r th of Jesus Chr is t s tands out at around 2018 years ago, the Roman empire was beginning to form as a con-cept , the Class ica l medica l text the Huangdi NeiJ ing was just begin-n ing to be wr i t ten, Ancient Egypt was drast ica l ly changing to what we understand of them today, and the wor ld’s v iew was that we were the center of the universe wi th the Sun t ravel ing under the ground at sunset through r ivers of lava, and ar is ing in the morning on the other s ide at sunr ise .

Acupuncture’s r ich anc ient h is tory i s ref lected in the medic ine. The stor ies of acupuncture’s power-fu l heal ing have been to ld about cur ing the cr ippled and tak ing pain away f rom the suffer ing. Cont inuing today wi th reports of dramat ica l ly reducing, and in many cases tota l ly a l lev iat ion of , severe and chronic cr ippl ing nerve pain , to the walk ing of recent para lyzed pat ients , to the heal ing of t i ssues never thought could be healed. Al l of these anec-dota l ly s tor ies do not fa l l short in the area of miraculous ly fantast ic , ‘myst ica l ’ , pre-sc ient i f ic era , and even tota l ly unbel ievable, but i s there any rea l sc ience that expla ins how th is powerfu l anc ient ar t of heal ing works , and equal ly import -ant , can we communicate that to our pat ients and other profess ional heal thcare pract i t ioners?

Tradi t ional Chinese medic ine’s f i r s t c lass ica l medica l text named the Huangdi NeiJ ing dates back to around 2 ,200-2 ,500 years ago. Most scholars of today wi l l p lace the composi t ion around the late Warr ing States of Sun Tzu , 475-221 BC, through to the Han dynasty around 206-220 BC. This medica l c lass ic has two sect ions , namely the Su Wen and Ling Shu . The L ing Shu is the f i rs t medica l text to descr ibe and out l ine acupuncture techniques and acupuncture t reatment pr inc i -p les , even l i s t ing acupuncture point prescr ipt ions for speci f ic medica l condit ions . This speci f ic sect ion seems to be where, we, the West , receive a lot of our fundamenta l in format ion about the mechanisms, and appl icat ions for acupuncture. I t i s in th is text where we f ind the important terms of de qi , mai , and j ing luo .

The term de qi i s recorded hun-dreds of t imes in the Ling Shu , and i t s tates how important i t i s that the pat ient must feel a de qi sen-sat ion in order for the t reatment to be effect ive. De qi i s s imply t rans-lated as “big qi”, or more common-ly as a qi sensat ion. There are even c lass ica l acupuncture de qi sensa-t ions recorded over the mi l lennium that are cons idered opt imal for pat ients to feel to achieve success wi th t reatment , such as feel ings of :

Dul l , achyFul lness , d is tens ionHeavinessHotColdPin pr ick , s l ight pain

In my book, “Neuropuncture: A Cl in ica l Handbook of Neurosc ience Acupuncture,” second edi t ion, I c lear ly corre lated each speci f ic de qi sensat ion wi th the speci f ic neu-ra l f iber that t ransmits that exact sensat ion. 1 Whenever our pat ients feel that heavy de qi sensat ion, then i t can only occur i f the A-del -ta f ibers have been st imulated by the needle, or more accurate ly by the loca l chemical soup that i s produced when needl ing, that s t imulates the t ransmiss ion of that sensat ion to the bra in . I look at th is as when my pat ient feels the de qi sensat ion, then I have reached my target , the bra in . We a l l remember the mult ip le hand needle s t imu-lat ion techniques that are taught to us to generate d i fferent de qi sensat ions that are associated wi th speci f ic t reatment pr inc ip les , such as wagging the blue-green dragon’s ta i l , s iphoning, rotat ion, twist ing, f i re on the mounta in , pounding, scrapping, etc . Wel l , those hand techniques a l l produce a specia l chemical soup local ly that in i t iates the profound heal ing react ion that occurs wi th acupuncture. 1 Th is chemical soup has been an-a lyzed and conf i rmed to inc lude red blood cel l s , whi te b lood cel l s , exc i tatory amino ac ids , prostaglan-dins , h is tamine, NGF (nerve growth factor ) , and CGRP (ca l ic i tonin gene-re lated pept ide) . 1 CCRP is one of the body’s s t rongest natura l vasodi lators , which loca l ly encour-ages more ‘pool ing’ of that soup. We somet imes can see th is dur ing a t reatment as the redness that c i rc les the needle af ter insert ion. This helps to expla in how and why loca l needl ing is so effect ive for condit ions such as in fect ions , in-f lammat ion, and for t reatments for condit ions such as p lantar fasc i i t i s , and even tennis e lbow. In the t reat-ment of acute and chronic pain i t

has a lso been conf i rmed that wi th e lect roacupuncture techniques, a t ra ined pract i t ioner can target spe-c i f ic endogenous opioid receptors for the re lease of speci f ic endoge-nous opioid pept ides . 1 For example 2hz mi l l icur rent has been shown to target the Mu receptor for the re lease of beta-endorphins . Just as 4hz targets the Del ta receptor for enkephal in re lease, and 100hz targets the Kappa receptors for dy-norphin re lease in the spina l cord. 1 A sk i l l fu l pract i t ioner can apply th is neurosc ience knowledge to thei r c l in ica l pract ice qui te eas i ly wi th great effect . What i s important i s that the pract i t ioner understands why these effects occur, so adjust -ments can be made f rom t reatment to t reatment for maximum c l in ica l outcomes.

Us ing neuroanatomy we can a lso examine how dista l acupuncture points on the extremit ies can very much effect v iscera l funct ion. When we invest igate the neuroanatomy of the spina l segments we f ind severa l amazing facts . F i rs t , speci f ica l ly at the locat ion of the dorsa l horn of the spina l cord the somat ic and v iscera l nerves converge into the one t ract leading up to the bra in , the spinothamal ic t ract . This spina l neura l ref lex i s ca l led the muscu-larv iscera l ref lex and there i s a lso a cutaneousv iscera l ( sk in to organ) ref lex that expla ins Japanese sty le acupuncture. What th is means i s that when needl ing an acupunc-ture point , let ’s use the t radi t ional acupuncture point Stomach 25, that point i s located on the T10 der-matome, when st imulated the neu-ra l t ransmiss ion wi l l enter the spi -na l cord at the T10 level . So, what v iscera l nerves a lso innervate at the level of T10? The stomach, spleen, pancreas , and the smal l intest ine spina l nerves a l l have branches that innervate at T10. That means when needl ing and st imulat ing St 25 , you wi l l be a lso affect ing those organs and i t i sn ’t surpr is ing how St 25 i s a great point for d igest ive condi-t ions , especia l ly const ipat ion.

The second powerfu l neuroana-tomical fact i s that when a d is ta l acupuncture point i s s t imulated and the t ransmiss ion innervates the spina l cord, at the level of the dor-sa l horn where that a fferent t rans-miss ion innervates , three powerfu l neuropept ides are re leased. 1 Those neurochemicals are serotonin , noradrenal in , and enkephal in . Al l three chemicals a id in down regu-lat ing ANY pain s ignals coming in at that speci f ic level , but a lso any t ransmiss ion pass ing through that level ascending up to the bra in . We

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may ask ourse lves why, and how, i s Large Intest ine 4, Hegu, such an in-credible point for pain? Or why are some of the “extra” points in that area so wonderfu l at a l lev iat ing ANY pain in the body, even i f i t i s sc iat ica? Wel l , when st imulat ing L I 4 , you are d i rect ly s t imulat ing the branches of the superf ic ia l radia l nerve. The radia l nerve connects to the brachia l p lexus and that p lexus innervates the spine at the levels of C5-T1 ( the radia l nerve is the upper branch and is associ -ated wi th C5 innervat ion) . When that neurotransmiss ion passes thru the radia l nerve, a long the brachi -a l p lexus and then into the spina l cord at C5, those three powerfu l neurochemicals are re leased and wi l l then down regulate ANY pain s ignals pass ing thru that area of the spine ascending to the bra in . I f we understand th is effect , i t does not surpr ise us that L I 4 , or any of the extra points found local ly, has a powerfu l e ffect on pain anywhere in the body. Another fun fact i s that fMRI imaging has revealed that L I 4 has neura l branches that terminate in the hypothalamus and when st im-ulated i t re leases beta-endorphins that act ivate the PAG (per iaqueduc-ta l gray ) , which is the pain s tat ion for the ent i re body. 1 Wow, i s that awesome or what? Now communi-cate that in your next meet ing wi th any western heal thcare pract i t ioner and te l l me you won’t have thei r at tent ion!

The TCM energet ic model i s sc i -ent i f ica l ly controvers ia l , yet to be conf i rmed, and understood by many to be h is tor ica l ly mist rans lated. Do we conta in e lect r ica l energy? Yes . Do we omit e lect romagnet ic f ie lds? Yes . Great whi te sharks have these anatomical s t ructures named “am-pules of lorenz in i ,” that detects ex-act ly th is , the e lectromagnet ic f ie ld of thei r prey. Our heart generates an e lectromagnet ic f ie ld that ex-pands about 3 meters in d iameter every t ime our heart beats , and our b lood produces an e lectromagnet ic f ie ld due to the i ron i t c i rcu lates 2. Does th is equate to what i s com-monly understood as y ing qi , the qi that c i rcu lates in the ‘pathways ’ in TCM? I do bel ieve so but not in a myst ica l , non-sc ient i f ic rea lm. In the L ing Shu, i t c lear ly s tates many t imes that some of these pathways can be seen wi th the naked eye under the sk in , and that they a l l once or ig inated f rom the heart and that they conta in the blood and nutr ients absorbed by the digest ion and then c i rcu lated throughout the body for heal th . I f you ask me, I be-l ieve that the Chinese anc ient phy-s ic ians had an astute understanding

of the c i rcu latory, and nervous system, centur ies before the West , and there i s not one acupuncture phenomenon that I cannot expla in us ing neurophys io logy. The term mer id ian came f rom a French phy-s ic ian in 1908, which t rans lated mai and j ingluo as ‘mer id ian’ due to h is own personal energet ic ideology. I have seen better t rans lat ions as s imply pathway, or vessel . I urge you to replace the term ‘mer id i -an’ wi th ‘pathway’ or ‘vessel ’ , the next t ime you read i t in a Chinese medica l c lass ic and see how that changes your point of v iew.

Does re invest igat ing acupuncture wi th neurosc ience subtract any of the powerfu l appl icat ions to acu-puncture? Does i t degrade i ts long h is tor ica l presence? W i l l apply ing neuroanatomy to the TCM acu-puncture model take anyth ing away f rom th is powerfu l medica l t reat-ment? No, No, and NO!!! I t only conf i rms what our Chinese medica l forefather ’s were observ ing and i l luminates the authent ic i ty of our medic ine, and galvanizes acupunc-ture into the future of mainst ream medic ine. I t i s pract iced th is way in China, Korea, and many European countr ies , and i t seems l ike Amer-ican’s missed that subt le , yet pow-er fu l , adjustment . I have devoted my profess ional career to learn ing and educat ing my col leagues in th is exact area. I am current ly involved in ground break ing e lectroacupunc-ture research invest igat ing spina l nerve regenerat ion, s tem cel l pro-l i ferat ion, and much more. P lease cont inue to educate yourse l f and ra ise the bar of s tandards for our profess ion by being able to prop-er ly communicate the how, and why our medic ine works .

REFERENCES

1) Corradino M. Neuropuncture: A Cl in ica l Handbook of Neurosc ience Acupuncture. 2nd ed. Jess ica K ing-s ley Publ ishers ; 2017.

2 ) Becker RO. The Body E lectr ic : E lect romagnet ism and the Founda-t ion of L i fe . 1st ed. New York , NY: W i l l iam Morrow & Co. , Inc ; 1985.

NEUROPUNCTURE: SOLIDIFYING ACUPUNCTURE’S AUTHENTICITY (CONT.)by Michael Corradino, DAOM, MTOM, L .Ac

Dr. Michael Corradino, Doctor of Acupuncture and Or ienta l Medi-c ine, and Founder/CEO of Neu-ropuncture LLC, graduated f rom Paci f ic Col lege of Or ienta l Medi-c ine, Cum Laude, in 1995 wi th h is Masters in Tradi t ional Or ienta l Medic ine af ter s tudying molecular b io logy at Seton Hal l Univers i ty. Dr. Corradino is a publ ished author and internat ional speaker in the area of neurosc ience and acupunc-ture, and he is current ly involved in groundbreaking research wi th e lec-t ro-acupuncture and stem cel l pro-l i ferat ion, sp ina l cord in jury, opio id t i t rat ion, and oncology. Current ly Michael has a pr ivate pract ice in San Diego, whi le developing and teaching Neuropuncture g lobal ly.

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MOXIBUSTION THERAPY IN THE TREATMENT OF RADIATION FIBROSIS OF THE THROATDr. B ianca Di Giu l io , DAOM, L .Ac. | Dr. James Munson, DAOM, L .Ac.

ABSTRACT

Head and neck cancers are less common than other neoplast ic d isease, account ing for approxi -mately 3% of cancers in the Uni ted States . 1 The fo l lowing case study demonstrates the c l in ica l benef i ts of moxibust ion therapy, a modal i ty wi th in the pract ice of t radi t ional Chinese medic ine (TCM), for radi -at ion f ibros is of the throat . Th is condit ion was caused by extens ive radiat ion therapy in the t reatment of s tage I I la ryngeal cancer in a f i f -ty -n ine year-o ld male pat ient . The s ide effects of radiat ion therapy led to chronic swel l ing and hardening of the t i ssue affect ing the t rachea and vocal chords, which requi red a semi-permanent t racheostomy tube. Radiat ion oncologists est i -mated the tube would remain for approximately 2-4 years .

At the t ime of the in i t ia l v is i t , the tube had been in p lace for ten months . The pat ient sought Chinese medic ine t reatments to a l lev iate the phys ica l d iscomfort caused by f ibros is , inc luding local -i zed pain , d i ff icu l ty swal lowing and speaking. The dispers ion method of d i rect moxibust ion therapy on

speci f ic areas of the throat pro-v ided s igni f icant improvement and resul ts . In combinat ion wi th loca l e lect ro-acupuncture and pr ick ing therapy, pos i t ive outcomes were achieved af ter only three t reat-ments . A s igni f icant decrease in the f ibrot ic t i ssue of the affected area was measured at each fo l low-up v is i t indicat ing pos i t ive resul ts .

UNDERSTANDING DIAGNOSIS AND TREATMENT FROM A WESTERN MEDICAL PERSPECTIVE: LARYNGEAL CANCER

Laryngeal cancer i s a type of head and neck cancer. Mal ignant ce l l s are ident i f ied in the sof t t i ssue of the larynx, a part of the throat that res ides at the base of the tongue and t rachea. The anatomical s t ruc-ture of the larynx inc ludes three parts . F i rs t , the supraglott i s , the aspect above the vocal chords, the second is the glott i s , where the vocal chords are located, and th i rd i s the subglott is that s i ts between the vocal chords and the t rachea (windpipe) . The larynx i s respon-s ib le for the voice by way of the vocal chords that v ibrate when a i r i s d i rected at them. Squamous cel l s l ine the ins ide of the larynx where

cancer develops. 2 Major r i sk factors for th is type of cancer inc lude excess ive a lcohol consumpt ion and smoking. Acute phys ica l symptoms of d isease may begin wi th chronic sore throat , dysphagia and inabi l i ty to swal low sol id foods, ear pain , or awareness of a lump in the throat and changes in voice, l ike hoarse-ness . 2

The Western medica l d iagnosis i s achieved through var ious tests to determine exact s tage and loca-t ion of cancer. Af ter a complete heal th h is tory and phys ica l exam, the pat ient may be refer red for a chest x- ray or Bar ium swal low, a lso refer red to as an upper gast ro intes-t ina l ser ies . 2 This test requi res the pat ient dr ink a l iquid wi th bar ium to coat the esophagus and stomach before x- rays are taken. Abnormal i -t ies can a lso be discovered through laryngoscopy, in which a th in tube-l ike s t ructure i s inserted into the larynx to v iew and remove t i ssue samples . I f th is occurs the t i ssue is taken to pathology to screen for cancer. Other imaging may be requi red l ike computed tomogra-phy (CT scan) , pos i t ron emiss ion tomography (PET scan) , and bone scan. 2

The standard of care in convent ion-a l medic ine for laryngeal cancer inc lude the fo l lowing: surgery, chemotherapy, and radiat ion ther-apy. The method and course of t reatment i s dependent on mult ip le factors l ike degree of spread, type, s tage and heal th of the indiv idu-a l . External beam radiat ion ther-apy (EBRT) i s a common method of t reat ing many types of cancer, inc luding those of the head and neck. 2 EBRT funct ions by creat ing smal l beams of e lect romagnet ic waves ( radiat ion) that permeate the t i ssue in prec ise locat ions to erad-icate ce l lu lar d isease. Pro longed radiat ion therapy can cause a host of s ide effects , f rom superf ic ia l er-ythema of the sk in , and local sens i -t iv i ty, to deeper and more progres-s ive c l in ica l symptoms in the f ibers of musc le and soft t i ssue. 1

The effects of radiat ion can re-su l t in a condit ion refer red to as radiat ion f ibros is syndrome (RFS) . The t i ssue in the surrounding area becomes f ibrot ic , hardening into a f i rm mass , which in the case of head and neck cancers , can impact the vocal chords, esophagus, and abi l i ty to eat , speak and breathe normal ly. 3 Once th is occurs there are very l imi ted t reatment opt ions . Phys ica l therapy and speech reha-bi l i tat ion is necessary in most cases and are methods that are fami l iar to and approved by radiat ion on-cologists . Massage, heat therapy or myofasc ia l re lease is caut ioned due to the convent ional understanding that loca l manipulat ion or heat appl icat ion would lead to internal i r r i tat ion and inf lammat ion.

CASE STUDY: MOXIBUSTION THERAPY FOR RADIATION FIBRO-SIS SYNDROME

A f i f ty -n ine year-o ld male present-ed wi th acute radiat ion f ibros is of the throat due to EBRT he complet-ed n ine months pr ior, for s tage I I la ryngeal cancer. The pat ient re-ported that he f i rs t not iced discom-fort in h is throat wi th mi ld d i ff icu l ty swal lowing and intermit tent ear-aches. Due to the s low progress ion of symptoms he postponed seeking medica l t reatment , expect ing the discomfort to resolve. The pat ient has a h is tory of a lcohol ism and long-term tobacco use, which lead h im to ignore the symptoms and dismiss them as acute s ide effects of h is addict ions . The dysphagia u l -t imately worsened to an extent that he sought medica l care wi th h is pr imary phys ic ian. He was refer red for endoscopy wi th bar ium swal low to image the throat . Under genera l anesthes ia , t i ssue was removed, b iops ied and stage I I cancer was conf i rmed.

This s tage and pathology indi -cates a tumor that has not grown outs ide of the throat . There is no lymph involvement , nor spread to d is tant s i tes . S ince the tumor

s ize and lack of spread did not requi re surgery or chemotherapy, s tandard protocol was s ix weeks of da i ly radiat ion therapy. W ith in two weeks of complet ing the course of t reatment , he reported di ff icu l ty breath ing and exper ienced acute respi ratory d is t ress . He was rushed to the emergency room where a t ra-cheostomy was per formed. This i s a surgica l procedure wherein a hole i s made f rom a speci f ic point on the neck into the t rachea to a l low oxygen-r ich a i r to reach the lungs.

In th is part icu lar case, the t ra-cheostomy became a permanent outcome due to excess ive radia-t ion therapy caus ing f ibros is of the throat . The hardening of the t i ssue impacts the open passageway of the t rachea, becoming immobi le , f i rm, and compromis ing the s imple act of respi rat ion. Not only does th is a ffect the abi l i ty to breathe, but eat ing and swal lowing wi th RFS is a lso compromised. Consequent ly, the pat ient remained in the hospi -ta l for three weeks wi th a feeding tube and underwent rehabi l i tat ive therapy wi th vocal cord specia l i s ts , speech therapists , d iet ic ians , and phys ica l therapy.

This pat ient was refer red to our Chinese medic ine c l in ic approx-imately e leven months af ter the Western medica l procedures . A thorough intake indicated the RFS impacted act iv i t ies of da i ly l i v ing and overa l l wel lbeing. Three-month fo l low-ups wi th h is oncologist con-f i rmed he was cancer f ree. Despi te being c leared of mal ignancy, the pat ient expressed immense f rust ra-t ion wi th the t racheostomy tube. According to the pat ient , “the doc-tors and therapists have nothing e lse to offer. They say I just have to wai t i t out and hope the f ibros is decreases .”

W ith ease, he used h is t racheos-tomy tube to descr ibe h is symp-toms. Stat ing that internal ly h is throat fe l t ext remely dense. He was acute ly aware of an immobi le mass that never decreased in s ize . He gestured to h is throat and pressed f i rmly a long the s ides of the throat , across the sca lenes, b i latera l ly. As he pushed, he sa id i t was “hard as a rock.” There was no report of pa in , but he expla ined that he could feel tenderness and swel l -ing ins ide the throat loca l ly. The extens ive swol len area extended f rom just above the laryngeal prom-inence, to the jugular notch and approximately four inches latera l in both di rect ions .

Pa lpat ion by both pract i t ioners exhib i ted hardened, f ibrot ic t i ssue, warm to the touch, swol len, and v is ib ly red. Apply ing pressure d id not e l ic i t pa in . He expla ined there was a constant need to c lear h is throat , wi th a mi ld , chronic cough because of phlegm and sputum that would not f lush natura l ly through h is throat . He wore an ascot around

MOXIBUSTION THERAPY IN THE TREATMENT OF RADIATION FIBROSIS OF THE THROAT (CONT.)Dr. B ianca Di Giu l io , DAOM, L .Ac. | Dr. James Munson, DAOM, L .Ac.

h is neck, which, at the t ime of the in i t ia l t reatment , was adjusted to i ts la rgest c i rcumference.

He cont inued to expla in that the prev ious year had c lear ly a ffected h is phys ica l and emot ional heal th . His energy and stamina was report -ed as very low, he requi red s leep medicat ions to fa l l and stay as leep, and mainta ined a long h is tory of insomnia. His body tended toward hot , wi th des i re for cold dr inks , and a constant dry mouth. Pr ior to h is cancer d iagnosis , he was t reated for asthma, which requi red the use of inhalers dur ing act iv i ty. His b lood pressure was e levated requi r-ing prescr ipt ions . He exper ienced occas ional headaches and reported digest ion as normal . Prescr ipt ion medicat ion inc luded V icodin (as needed) , Prozac, L is inopr i l , and Xanax.

CHINESE MEDICINE DIAGNOSIS

The current academic l i terature for Chinese medic ine pract i t ioners seeking guidance for cancer pa-t ients i s l imi ted. Due to the very nature of cancer being a res i l ient-ly complex d isease, the ava i lable mater ia l i s not exhaust ive of every cancer, s tage, d iagnosis and t reat-ment . Therefore, c l in ic ians must d i l igent ly research and hone thei r c l in ica l sk i l l s to t reat pat ients wi th lesser-known or more rare tumors . Nasopharyngeal cancers ex is t wi th in that category. Fortunate ly, TCM phys ic ians can re ly upon pat-tern d i fferent iat ion, inc luding the e ight-pr inc ip les , inter ior-exter ior, and excess-def ic iency to proper ly d iagnose and effect ive ly t reat . Examinat ion of the pat ient ’s tongue and pulse demonstrated a mixed syndrome. This i s of ten t rue wi th indiv iduals d iagnosed wi th cancer and complex d isease patterns . The tongue body was red wi th deep cracks in the middle and upper j iaos , and a greasy-ye l low coat in the rear. The pulse fur thered th is pattern, the L iver was wi ry- fu l l , Spleen s l ippery, K idneys deep, th in , and the overa l l rate was rapid.

TCM diagnosis :

Upper j iao phlegm with tox ic heat , q i -b lood stagnat ion, K idney-L iver y in def ic ient heat

TCM treatment pr inciple:

Dissolve phlegm, c lear tox ic heat , c lear def ic ient heat , nour ish y in and ca lm spi r i t . E ffect ive Appl icat ion of Moxibus-t ion Therapy for Radiat ion F ibros is Syndrome:

Moxibust ion therapy was inst ru-menta l in the pat ient ’s reduct ion of symptoms as a resul t of RFS. Therefore, we have out l ined i ts appl icat ion as a s ingular, usefu l modal i ty for pract i t ioners . Theoret-ica l ly, moxibust ion may seem coun-

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ter intu i t ive in th is case given that heat therapy is genera l ly cons id-ered a contra indicat ion wi th s igns of heat , l ike redness or swel l ing. There is a concern i ts e ffects wi l l in f lame or worsen the condit ion. This i s especia l ly t rue wi th respect to phi losophy and c l in ica l appl ica-t ion in Western medica l paradigms. However, TCM re l ies upon the t reatment phi losophy of “ l ike t reats l ike ,” proven in th is case study wi th proper technique of moxibust ion therapy.

Safe method and appl icat ion of moxibust ion for th is case is h igh-l ighted below:

Type: coarse, green, low-grade moxibust ion was ut i l i zed to create an intense, s t rong dispers ing heat S ize : moxa was shaped into very t ight , f i rm cones in order to create a s low, intense heat (approximately the s ize of a Hershey’s K iss )Quant i ty : 4-6 cones were placed di rect ly on the pat ient ’s throat at speci f ic areas wi th most f ibrot ic , t ight , dense t i ssueMethod: Us ing an incense st ick , each cone was l i t and watched carefu l ly as i t burned toward the sk in . The cone was removed when the pat ient reported a sensat ion of heat d i rect ly under the cone, or the pract i t ioner est imated that enough heat had accumulated local lyTechnique: The cone was removed with forceps and placed in a cup of water. The point was not covered by the f inger to reta in heat , but rather to a l low the heat to d isperse internal lyDurat ion: This technique was re-peated on each point unt i l there were palpatory and/or v isua l chang-es , or the pract i t ioner deemed i t adequate for t reatment

The larger, t ight ly packed moxi -bust ion cone causes a longer burn t ime, which a l lows more heat to develop and fac i l i tate the scatter-ing of the heat tox in as wel l as to encourage wei q i (defens ive q i ) to the sur face and a id in the disper-s ion. In TCM theory, not imme-diate ly cover ing the point upon removing the cone, a l lows the heat/ev i l pathogen to ex i t . However, i t i s c ruc ia l that the pract i t ioner quick ly p lace the next cone in the same locat ion, i f necessary, to keep the heat at a s teady, h igh level .

In th is case, pa lpat ion and c lose v isua l examinat ion was integra l to decid ing how many cones were appl ied to each point . When the t i ssue sof tened and there was less dens i ty wi th pressure, th is indi -cated pos i t ive change and heat reduct ion. In addit ion, wi th c lose examinat ion,g the area became less swol len and red. I t i s important to s tate that th is type of technique needs to be done wi th the fu l l understanding and consent of the pat ient , and by those pract i t ioners who are exper ienced and conf ident wi th moxibust ion. In a case of RFS,

the integr i ty of the sk in , sensory funct ion, and normal sensat ion has been great ly compromised due to radiat ion therapy. By and large, Western-t ra ined doctors bel ieve heat i s contra indicated wi th s igns of swel l ing and redness , and as a resul t , caut ion pat ients to receive any k ind of phys ica l or manual therapy because of the h igher level of sens i t iv i ty. Thus, the pract i -t ioner needs to judge appropr iate s t rength of t reatment through thei r own sk i l l and observat ion wi thout re ly ing on the pat ient ’s feedback as they may not feel the heat acute ly.

Const itut ional Support: Acupuncture Therapy

Moxibust ion was an integra l com-ponent to a l lev iate d iscomfort and hasten heal ing of the f ibrot ic t i ssue. Given that Chinese medic ine is a synergist ic system that incorpo-rates mult ip le modal i t ies for heal -ing, const i tut ional acupuncture was a lso employed. The fo l lowing acu-puncture point combinat ions were inc luded as part of th is pat ient ’s sess ions . In tota l , he received only three t reatments , but substant ia l changes were ev ident fo l lowing each v is i t reported by the pat ient and observed by the pract i t ioners through palpat ion.

Treatment #1

Tongue: Red, deep cracks , s t icky ye l low coatPulse: wiry, ch i pos i t ions deep, Lung/Heart excess , s l ippery, s l ight ly rapid

Acupuncture :

Se i r in needles used for a l l acupuncture

Open Ren: LU 7 , K 6 - Pathway of the Ren channel courses through the throat- Combinat ion of ext raordinary mer id ians nour ishes y inOpen Chong: SP 4 , PC 6Ren 6 , Ren 12, Ren 14, Ren 22- Pa lpat ion a long the Ren mer id ian exhibi ted sk in changes in tone, texture, and temperature on the above noted points , which were then needled in d ispers ing methodLV 14- Spread L iver q iST 40- Clear PhlegmSP 9- Clear DampLocal : 2 ash i points on each s ide of the throat , approximately on Large Intest ine channel

Moxibust ion:

Dispers ing technique, d i rect cones p laced in 4 pos i t ions on throat and each appl ied three t imes. P lease see above sect ion for d iscuss ion and technique.

Results

Immediate ly fo l lowing th is t reat-ment , pa lpat ion on the throat and neck demonstrated sof t , more mal-leable t i ssue that sh i f ted s l ight ly wi th pressure. When the pat ient was asked to swal low, he reported that the mass of r ig id, f ibrot ic t i s -sue that enveloped h is throat had lessened, a l lowing more movement when he swal lowed. The ye l low coat on the tongue dispersed, h is pulses s lowed to a normal rate , and v isual ly, the systemic redness and inf lammat ion that was present on h is cheeks , forehead, and overa l l sk in tone, lessened.

Treatment #2

The pat ient returned two weeks later and reported he was able to decrease the length of h is ascot s ize down to a smal ler c lasp. He was very encouraged by th is quick response. Pa lpat ion indicated smal ler mass c i rcumference and the edges of the f ibrot ic area were less r ig id. He noted improvement in h is abi l i ty to swal low sol id food and a decrease in the tendency to c lear h is throat f rom rat t l ing phlegm. He reported that he did not need to take V icodin dur ing th is two-week per iod for throat pain . However, the pat ient d isc losed a long h is tory of a lcohol ism and stated he was beginning to at tend sobr iety meet-ings. Given that a lcohol i s a pr ima-ry r i sk factor to laryngeal cancer, the ce l lu lar pathology is rooted in th is condit ion, but a lso i l lust rates deeper emot ional roots and com-plex patterns that corre late to h is overa l l wel l -being and heal th .

The subsequent t reatment p lan inc luded moxibust ion, aur icu lar acupuncture to support a lcohol wi thdrawal , and an e ight ext raor-dinary mer id ian (EEM) protocol ut i l i z ing the Dai mer id ian to dredge and open the L iver and Gal lb lad-der, c lear heat , detoxi fy the system, and move and regulate q i . The Dai t reatment i s indicated for emo-t ional re lease and let t ing go - a lso therapeut ica l ly re levant for th is pat ient .

Tongue: red, deep cracks , s t icky ye l low coatPulse: wiry, K idney deep-th in , Lung/Heart s l ippery, s l ight ly rapid

Acupuncture:

Aur icu lar (b i latera l ) : Shen Men, L iv -er, Lung 1 , Sympathet ic , K idneyLocal (ash i throat , b i latera l ) : needle angled media l ly toward the mass , inserted approximately ½ cun- E lectr ica l s t imulat ion (e-st im) leads were placed on four of the throat needles , 10 hz , increased s lowly to a level where the pat ient reported a not iceable, cont inuous f requency- Needles reta ined for twenty minutes

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Open Dai : GB 41 ( le f t f i r s t ) , LV 13, GB 26, GB 28, Ren 15

Topical :

Zhen Gu Shui was appl ied topica l -ly at the end of the sess ion to the throat

Moxibust ion:

Indi rect heat appl ied wi th smoky moxa over areas of s igni f icant hard-ness us ing the dispers ing method. The moxa st ick i s held over the ident i f ied point , wi th the pract i -t ioner ’s hand placed between the heat and the sk in to moderate tem-perature. The moxa is held unt i l the heat esca lates and then the st ick i s pul led away for a moment , before return ing to the same pos i t ion. The point i s not covered wi th the sup-port ing hand in order to d isperse the heat .

Treatment #3

The pat ient returned to the c l in ic one week fo l lowing the second ses-s ion. The c i rcumference of the mass had decreased in s ize s igni f icant ly, which was conf i rmed by the pat ient not ing the ascot s ize was now at i ts t ightest poss ib le p lacement . He reported that internal ly h is throat fe l t less in f lamed, large, and swol-len and had “opened up.” There was a lso an ev ident sh i f t in h is emot ional s tate , observable f rom both the pract i t ioner ’s perspect ive, but a lso shared by the pat ient , and independent ly conf i rmed by h is daughter. He was making decis ions to return to rehab for h is a lcohol-i sm, and expressed more opt imism about h is heal th and the future.

Tongue: Red, deep cracks , th in- ye l low coatPulse: w i ry, rapid; Lung/Heart th in-s l ippery

Acupuncture:

LI 4 , LV 3- Class ic “4 Gates” point combina t ion to c i rcu late q i -b lood, move the L iver, toni fy q iST 40, SP 9- Resolve Damp and Phlegm Accu mulat ionRen 17, Ren 22- Open the chest and throat , de scend rebel l ious q iST 25, Ren 12, Ren 6- Class ic “4 Doors” point combinat ion to regulate d iges t ion, by nour ish ing Spleen-Stom ach qi , toni fy and ra ise q iLocal (ash i points , b i latera l ) : ap-proximately s ix acupoints a long the latera l aspect of the mass , accord-ing to palpat ion- E lectro s t imulat ion at tached on a l l s ix point locat ions , beginning w i th 10 Hz Pr ick ing therapy (b i latera l ly ) : ST 45, in-out needl ing method to c lear heat - The Stomach channel descends f rom the orbi ta l region, through

the throat , cu lminat ing on the 3rd toe at ST 45

Moxibust ion:

Indi rect , d ispers ion technique a long the throat combined wi th four rounds of d i rect cones on two local areas where th icker f ibrot ic t i ssue remained.

Results

After the th i rd t reatment the pat ient ca l led to report pos i t ive changes in the mass and associated symptoms, but decided to return to a rehabi l i tat ion center to ad-dress h is a lcohol ism. Al though the course of t reatment was qui te short and not the preferred durat ion to proper ly address h is concerns , both pract i t ioners were opt imist ic that wi th ongoing t reatments the f ibrot ic t i ssue would s lowly cont in-ue to sof ten and symptoms would improve as a resul t . CONCLUSION

This case study i l lust rates the range of t radi t ional Chinese medi-c ine techniques in the t reatment of cancer- re lated condit ions , l ike RFS. The s ide effect of radiat ion thera-py can extend f rom the superf ic ia l erythema, to deeper levels of sof t t i ssue changes requi r ing speci f ic and ref ined approaches. Al though the pract i t ioners were only a fford-ed three t reatments to address a wel l -establ ished condit ion, the c l in ica l outcome was ev ident . I t i s a lso important to note that wi th just a few moxibust ion cones and needles , immediate resul ts were at -ta ined. This speaks to the synergis-t ic aspect of TCM modal i t ies and how t reatments need not be over ly involved, especia l ly when appropr i -ate modal i t ies are used together as they were intended in c lass ica l Chinese medic ine.

REFERENCES

1) Amer ican Society of Cl in ica l On-cology: Head and Neck Cancer Sta-t i s t ics 2017. Alexandr ia , Va. ht tps : //www.cancer.net/cancer- types/head-and-neck-cancer/stat is t ics . Accessed March 27, 2018.

2 ) Nat ional Inst i tute of Heal th- Na-t ional Cancer Society. Laryngeal Cancer Treatment (Adul t ) . ht tps : //www.cancer.gov/types/head-and-neck/hp/adul t/ laryngeal - t reat-ment-pdq. Accessed March 15, 2018.

3 ) Hojan, K . , & Mi leck i , P. (2014) . Opportuni t ies for rehabi l i tat ion of pat ients wi th radiat ion f ibro-s is syndrome. Reports of Pract ica l Oncology and Radiotherapy, 19 (1 ) , 1–6. ht tp://doi .org/10.1016/ j .rpor.2013.07.007.

MOXIBUSTION THERAPY IN THE TREATMENT OF RADIATION FIBROSIS OF THE THROAT (CONT.)Dr. B ianca Di Giu l io , DAOM, L .Ac. | Dr. James Munson, DAOM, L .Ac.

Bianca Di Giu l io i s a Doctor of Acu-puncture & Or ienta l Medic ine and has been in pract ice for over ten years wi th a specia l ty in Chinese medic ine oncology, support ing the cancer pat ient toward heal th and heal ing.

James Munson is a Doctor of Acupuncture & Or ienta l Medic ine dedicated to improving h is pa-t ient ’s heal th and prevent ing i l lness ut i l i z ing the system of t radi t ional Chinese medic ine.

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“Present ly she cast a drug into the wine of which they drank to lu l l a l l pa in and anger and br ing forget fu l -ness of every sorrow.” 1 The inebr i -ant descr ibed in Homer’s “Odys-sey” depicts the equiva lent drug exper ience current ly overwhelming the Uni ted States : opio ids . This c lass of drug has taken many forms throughout h is tory, f rom opium to fentany l and has p layed a major ro le in in f luencing c iv i l i zat ion. This i s by v i r tue of the neurobiologica l a ff in i ty humans have for i t ’s euphor-ic and pain- reducing effects . The over re l iance on opioids as tools has lead to mi l l ions in the c lutches of addict ion and an current est i -mated average of 115 people a day dy ing of acc identa l overdose in the Uni ted States . 2,3 From an epidemiologica l perspect ive, the current problems associated wi th opiate abuse are not a ffect ing a l l demographics equal ly. Consequent-ly the current pol i t ica l approach being taken has a d i fferent rhetor ic compared to other drug epidem-ics , l ike that of the crack-cocaine epidemic of the 1980’s . 4 Neverthe-less , wi th Pres ident Trump’s dec-larat ion of th is as a publ ic heal th emergency and more recent gr im threats for t ra ff ickers , 5 legis lators , community leaders , and heal th care prov iders are looking for answers . I t i s imperat ive to look at fa i l ings of past drug cr ises as so lut ions are formulated. Rev ised tools for pain and addict ion are needed to help the thousands desperate for help, many of which are offered by integrat ive medic ine. Tradi t ional Chinese Medic ine and other modal-i t ies of integrat ive medic ine offer many tools for pain management and addict ion t reatment . In order for these modal i t ies to be success-fu l in decreas ing opioid use and dependence, they must be embed-ded in larger publ ic heal th effor ts and a l igned wi th key publ ic heal th pr inc ip les : prevent ion, equi table access , and compass ion.

According to the Center for Dis-ease Contro l , one out of every f ive people d iagnosed wi th a pain d isorder i s prescr ibed opioids . 2 An est imated 2 .1 mi l l ion people suf -fered f rom substance abuse re lat -ed to opioids in 2012. 2 According to the Kaiser Fami ly Foundat ion, the number of acc identa l opio id overdoses doubled in f ive years between 2011 to 2016. 6 The Amer i -can Society of Addict ion Medic ine c i tes drug re lated overdoses as the leading cause of acc identa l death in the Uni ted States , surpass ing car acc idents . Furthermore, four out of f ive heroin users s tar t wi th the mis-use of prescr ipt ion paink i l lers . 7

ETHNOBOTANICAL HISTORY

Humans’ re lat ionship wi th opio ids spans mi l lennia . To understand the issue in the broader scope of h is tory, i t ’s worthwhi le to look at the re lat ionship humans have had wi th th is drug over t ime. Opioid drugs may be der ived f rom the opium poppy (Papaver somni ferum ) as e i ther natura l drug iso lates l ike morphine or semi-synthet ic com-pounds l ike oxycodone; or they may be fu l ly synthet ic l ike fentan-y l . Opium poppy cul t ivat ion dates back to 3400 B.C.E. , in the f i rs t known human c iv i l i zat ion of Meso-potamia. 8 I t was then passed down to major anc ient c iv i l i zat ion, in-c luding the Egypt ians , Babylonians , and Chinese. 9 Opium was int ro-duced to modern Western medic ine in the 16th century in the form of laudanum, an a lcohol ext ract of the poppy by Swiss doctor and a lche-mist , Paracelsus . 10 Morphine, one of i ts act ive a lka lo id const i tuents was f i rs t i so lated in 1805 in Germany and has been used by phys ic ians ever s ince. 11 Short ly a f ter, the Uni t -ed Kingdom went to war wi th China over the t rade of the poppy in the f i rs t of two Opium Wars f rom 1839-1842. 12 Around th is t ime, thousands of pounds of opium were annual ly imported into the Uni ted States and the famed “Opium Dens” of San Francisco were prevalent . In 1973, the Drug Enforcement Agency (DEA) was created by Pres ident Nixon to address the growing r i se of heroin use. 9 In present day, the Uni ted Nat ions reported the product ion of opium poppies in Afghanistan reached a record h igh in 2017, caus ing a larm for i ts impl icat ions on the ongoing wars and global drug t rade. 13 Meanwhi le , in the Uni ted States , pharmaceu-t ica l companies who produce and dist r ibute opioid medicat ions , l ike McKesson, are some of the most prof i table in the wor ld, report ing $198.5 b i l l ion revenue in 2017. 14

This t imel ine i l lust rates Papaver somni ferum’s fa r- reaching impact on h is tory. The va lue and s igni f i -cance th is p lant has p layed cul tur-a l ly i s hard to fathom. Anthropol-ogist , P.G. Kr i t ikos , descr ibed how the poppy was used in re l ig ious r i tua l by the anc ient Greeks as a euphor iant . 15 16 By the Sumer ians , i t was known as “hul g i l” or joy p lant . 15 Meanwhi le , i t was va lued as a medic ine a l l over the wor ld as i t t raveled a long the S i lk Road. Though di fferent cu l tures may have had dis t inct medica l appl icat ions , i t i s c lear P. somni ferum’s most compel l ing effects are on sh i f t ing consc iousness and a l lev iat ing pain .

AN INTERDISCIPLINARY PERSPECTIVE ON THE OPIOID CRISISby Elena Roemer, DACM Candidate

BASIC NEUROSCIENCE OF OPIOIDS

To understand why th is medic ine is so powerfu l ly effect ive, i t i s he lpfu l to understand i ts bas ic mechanism in the bra in . Endorphins (short for endogenous morphine) are a c lass of neurotransmit ters natura l ly produced by the body that e l ic i t p leasure and are involved in pain mediat ion. Endorphins are s t ructur-a l ly re lated to exogenous opioids , and both work at the same recep-tor s i tes in the centra l nervous system. 17 These receptors are l ike a lock that f i t s the keys of both the endogenous (endorphins : Beta endorphin and enkelphins ) and exogenous opioids (oxycodone and heroin ) . However, the pharmacolog-ica l prof i le of the exogenous opi -ates are s t ronger and consequent ly they have severe s ide effects . 17

The s ide effects of these exog-enous opiates have been noted throughout h is tory. According to ethnobotanist MJ Brownste in , “Star t ing in the 16th century, manuscr ipts can be found descr ib-ing drug abuse and to lerance [ to opium] in Turkey, Egypt , Germany, and England.” 15 Tolerance is the crux of the current cr i s i s , as one of the expected s ide effects of tak ing medicat ions l ike V icodin and OxyCont in . W ith repeated use, the pain re l iev ing effects of opio ids are d imin ished due in part to a decreased sens i t iv i ty at the recep-tor s i te , and users increase the dose in order to get resul ts . 18 Th is esca lates the r i sks of dependence, addict ion, and adverse effects l ike const ipat ion, nausea, and respi ra-tory depress ion. 19

Abuse of an opioid of ten begins when an indiv idual exper iences the sense of euphor ia brought on by the drug and then t r ies t ry re-create these feel ings. This may be done wi th techniques l ike nasa l inhalat ion, in ject ion, or increas ing the dosage. 20 Opioid abuse a lso changes the level of dopamine in the bra in , associated wi th feel ings of exc i tement , and prov ides pos-i t ive re inforcement for cont inued abuse. 17 Long-term opioid use caus-es the bra in to produce less of the var ious neurotransmit ters , inc lud-ing dopamine, serotonin , GABA, and endorphins due to the over-whelming surge caused by us ing the drug. 17 18 When the bra in s tops producing i ts own neurotransmit -ters to feel good, the user feels more drawn to cont inue us ing opi -o ids . As these bio logica l processes occur and levels of dependence become severe, users become des-

22

perate to mainta in th is new level of basel ine. Also seen in th is current cr i s i s i s when access to prescr ip-t ion opioids becomes unavai lable , people s t ruggl ing wi th addict ion wi l l turn to the re lat ive ly inexpen-s ive and readi ly ava i lable a l terna-t ive heroin . 7, 13 According to the CDC, the rate of heroin overdoses increased f ive fo ld between 2010 to 2016. 21 Those being sold heroin are of ten given a concoct ion of d i ffer-ent opio ids , somet imes conta in ing the h ighly potent synthet ic opiate Fentany l , which has led to s tagger-ing overdose rates . 22

EASY ACCESS

Unt i l recent ly, opio ids have been a pr imary t reatment for a wide var iety of pa in d isorders by b iomedica l heal th care prov iders . In response to the current cr i s i s , the CDC is -sued new guidel ines for safer prac-t ices in prescr ib ing these medica-t ions in order to curb problemat ic over-prescr ipt ion by doctors . 23 Be-tween 1998 and 2010, the amount of opio ids d ispensed by pharmacies in the U.S. doubled. 24 In 2013, there were enough prescr ipt ions wr i t ten for every Amer ican to have thei r own bott le of p i l l s . 2 Some states have more paink i l ler prescr ipt ions than there are people l iv ing in that s tate . 2 25 Nonetheless , over 75% of people abus ing opioid paink i l lers are not gett ing i t d i rect ly f rom thei r doctors , but f rom ei ther a f r iend, re lat ive , drug dealer, or off the in-ternet . 25 Though the problem may or ig inate in the doctor ’s off ice , the pleasurable and addict ive nature of th is substance lends i tse l f to prol i f -erate out into communit ies . In 2015, whi le law enforcement effor ts cont inued on st reet drugs, legis lators eased regulat ions on incoming opioids f rom the pharma-ceut ica l industry under the pressure of h ighly a ff luent lobbyists . 26 The law is ca l led the “Ensur ing Pat ient Access and Effect ive Drug Enforce-ment Act” 27 and effect ive ly weakens DEA rest r ic t ions on the top com-panies who produce and dist r ib-ute opioids l ike Cardinal Heal th , McKesson, and Amer isourceBergen. This a long wi th the surplus of Mexi -can and Afghan produced heroin ,13 resul ted in an explos ion in ava i l -abi l i ty of opio ids in the country. 28, 29

AVAILABLE TREATMENT OPTIONS

The U.S. now f inds i tse l f wi th the major quest ion of how to address the thousands of newfound ad-dicts . Whi le there are programs in ex is tence for many suffer ing for addict ion, some t reatment opt ions

are s imply out of reach. For exam-ple, the average cost of an inpa-t ient pr ivate ly run rehab program can range between $6000-$20,000 a month. 30 The Affordable Care Act of 2010 requi res insurance prov iders to cover addict ion serv ices , though very few t reatment centers actu-a l ly accept th is type of insurance, inc luding Medica id. 31 A l ternat ive t reatment centers are ava i lable . For example, the Sa lvat ion Army offers serv ices for those wi th low to no income or insurance, yet these are s tate- funded or non-prof i t ent i t ies re ly ing on donat ions or government a l located resources . The pr imary medica l t reatment for opio id addict ion is Methadone and Buprenorphine, drugs that act as a replacement for prescr ipt ion opioids or heroin . Methadone, a fu l l opio id receptor agonist , i s the gold standard for t reat ing addic-t ion, however th is substance is a lso a h ighly addict ive substance and i t ’s use is s t igmat ized. 32 Buprenor-phine on the other hand, i s only a part ia l opio id receptor agonist and therefore does not have the same euphor ic effects of methadone. However, Buprenorphine is not as readi ly access ib le as Methadone. 33 Other medica l t reatment opt ions l ike Nal t rexone and V iv i t ro l , opio id antagonists that prevent effects of opiates , have not been shown to be effect ive when compared to p la-cebo. 33 Psycho-socia l intervent ions l ike work ing wi th a psychotherapist , jo in ing a peer support group l ike Narcot ics Anonymous, and hav ing support ive soc ia l network a lso p lay a cr i t ica l ro le in t reatment , . 33 INTEGRATIVE MEDICINE SOLUTIONS

The medica l community cont in-ues looking for so lut ions for th is cr i s i s both downstream for t reat-ing pat ients addicted opioids and upstream in help ing pat ients manage pain . W ith the new st r ic ter CDC opioid prescr ib ing guide-l ines , prov iders have fewer opt ions to support thei r pat ients . Thus integrat ive medic ine may play an integra l ro le in prov id ing a l ter-nat ive approaches to t reatment and pain management . Chinese phi losophy’s c lass ic ax iom on pain s tates : “ I f there i s f ree f low, there i s no pain ; i f there i s no f ree f low, there i s pa in .” Tradi t ional Chi -nese Medic ine (TCM) has a broad lex icon for descr ib ing the or ig ins of pa in ; for example i t can be due to: b lood stas is , q i s tagnat ion, cold congeal ing, heat , and Bi syndrome. W ith th is breadth of et io logy and sophist icated diagnost ic lens , acu-

punctur is ts have a large toolbox for managing pain wi th acupuncture and herbs . Acupuncture analges ia i s supported by many randomized contro l led t r ia ls on both on humans as wel l as an imals : one of the wel l researched theor ies on i t ’s mecha-nisms of act ion is by work ing on the endorphin system. 34, 35 , 36 , 37 , 38 A long wi th the growing body of ev idence, acupuncture has thousands of years of empir ica l pract ice showing i ts safety, e ff icacy, and minimal s ide effects . In addit ion to acupuncture, there are many herbal medic ine therapies f rom both Eastern and Western t radi t ions that can be implement-ed for managing pain . Yan Hu Suo (Corydal is ch ines is ) and Cal i forn ia poppy (Eschscholz ia ca l i forn ica ) a re both herbs in the Papveracea fam-i ly, the same as the Opium poppy, that act at the same opioid recep-tor s i tes to reduce pain . 39 Curcum-in , an act ive compound in Turmer ic , has recent ly gained major popular-i ty in the West for pain and inf lam-mat ion. In a systemat ic rev iew when Curcumin was put in a head to head against NSAIDS ( Ibuprofen , ) the re-su l ts found s imi lar s igni f icant pain reduct ion over the 4-6 weeks of the study’s durat ion. 40 There are severa l c lass ic Chinese herbal formulas l ike Shen Tong Zhu Yu Tang and Shao Yao Gan Cao Tang, which are t ra-di t ional ly used to move the blood, have been shown in to be effect ive for decreas ing pain . 41,42 The lat ter formula conta ins Bai Shao (Paeonia lact i f lora , ) h igh in ant i - in f lammato-ry, pa in modulat ing polyphenols , 43

and Gan Cao (Glycyrrh iz ia g labra ) which conta ins pre-cursors to cort i -costeroids that have ant i - in f lamma-tory effects 44. Even cannabis (Can-nabis sat iva) though perhaps laden wi th i t ’s own potent ia l for abuse, may be a helpfu l harm reduct ion tool for mediat ing chronic pain . 45 There is a lso interest ing research suggest ing the co-administ rat ion of cannabis wi th opio ids i s safe and increases analges ic effects , and may a l low prescr ibers to decrease opioid dos ing. 46 Addit ional ly, in s tates where medica l cannabis i s le-gal i zed compared to s tates wi thout these laws showed a reduct ion in opio id overdose morta l i ty by 24.8% that increased over t ime. 47

Addit ional ly, integrat ive medic ine has many tools to offer pat ients wi thdrawing and t ry ing to overcome st ruggles wi th addit ion. Acupunc-ture i s a great modal i ty for support -ing opioid detoxi f icat ion and re-ducing crav ings, part icu lar ly us ing the aur icu lar Nat ional Acupuncture Detoxicat ion Associat ion (NADA)

23

protocol . 48 Acupuncture and herbs , inc luding Chinese formulas , can be helpfu l for managing the s ide ef -fects of wi thdrawal : insomnia, body aches, d iar rhea, musc le spasms, and nausea. 49 Many herbs used to support the nervous system, or “Spi r i t” as i s descr ibed in TCM, a lso p lay a v i ta l ro le in support ing the emot ional aspect of ten integra l in addit ion and recovery. 50

HEALTH INEQUITIES IN THE OPI-OID CRISIS

Integrat ive medic ine, acupunc-ture in part icu lar, f inds i tse l f in an in f luent ia l pos i t ion in th is cr i s i s , as i t i s able to t reat both pain and the compl icat ions of addict ion. As these modal i t ies cont inue gain ing popular i ty and recognit ion, the hope is that access a lso cont inues to expand. This i s essent ia l as the burden of the cr is i s fa l l s on those who have the least ava i labi l i ty of a l ternat ive opt ions . 51 This i s where pol icy could play a cr i t ica l ro le : en-sur ing these t reatments are acces-s ib le for anyone on the soc io-eco-nomic sca le and that barr iers to entry are removed. Severa l surveys have shown that as ide f rom Asian communit ies , minor i ty pat ients and those of lower soc ioeconomic s tatus are not as l ike ly to use acu-puncture. 52 A d ispar i ty ex is ts across a l l heal th serv ices for minor i ty pat ients 53, and especia l ly for pain management . The dispar i ty in the case of acupuncture use is of ten due to cost 52. However, one study looking at use rates by minor i ty ad-olescents at f ree acupuncture c l in ic in an urban hospi ta l set t ing showed that when th is barr ier i s removed, d iverse communit ies are more l ike ly to use acupuncture. 52

Interest ingly, the current opio id cr is i s i s not equal ly d iv ided a long rac ia l l ines : i t i s pr imar i ly a prob-lem for White Amer icans . In 2015, according to the Kaiser Fami ly Foundat ion, of the 33,091 people who died of an opioid re lated over-dose, 27 ,056 were White , non-His-panic . 6 This means less than 20% of the tota l overdose deaths are people of color (POC) . Interpreta-t ions of th is data have pointed the cause to be f rom rac ia l and ethnic d ispar i t ies in pain management 53. POC are less l ike ly to receive opioid prescr ipt ions than non-his -panic whi te pat ients for a var iety of pa in condit ions . 54 This d i fferent ia l behavior by prescr ibers i s l inked to inherent b iases and stereotyping minor i ty pat ients 55; for example being concerned pain compla ints are merely for seeking drugs or that POC pat ients may se l l thei r p i l l s . 56

Though th is pre judice may be hav-ing a protect ive effect for POC, th is may a lso mean they are gett ing less than adequate t reatment for thei r pa in . Being that the opioid cr is i s i s pr imar i ly a ffect ing whi te Amer i -cans , the pol i t ica l language used to descr ibe the problem shi f ts , as wel l as how to deal wi th the drug users . S ince the advent of the gov-ernment- led “War on Drugs” in the 1970’s , the use or abuse of speci f ic drugs has been seen as a cr iminal just ice i ssue, implement ing harsh sentences such as the three st r ikes pol icy and mandatory min imum sentences for i l legal drugs. This approach not only fe l l short of i t s promise to reduce drug use, i t a lso resul ted in severe rac ia l in just ice in our pr isons . Men of color are d is -proport ionate ly targeted by pol ice for drug cr imes, at a rate of f ive to one. 57 Furthermore, even though the current numbers show a d ispro-port ionate number of whi te abus-ers in th is opio id cr is i s , there are s t i l l more POC being charged wi th opio id and heroin re lated offens-es . 58 However, wi th the whi te face of the current drug cr is i s , the v iew of drug user sh i f ts f rom cr iminal requi r ing punishment to pat ient needing rehabi l i tat ion. Legis lators are h i t hard to f ind t reatment for the people s t ruggl ing wi th addic-t ion in thei r d is t r ic ts , as hundreds die monthly ; most of whom look l ike them. 59 However, the numbers of th is current cr i s i s could be com-pared to those of the crack cocaine cr is i s of the 1980’s and 90’s 60, a f -fect ing most ly urban black commu-ni t ies ; though the approach of th is era was not one of compass ion. 4 This i s again mir rored in the heroin cr is i s of the 1970’s , “wi th a puni t ive approach to b lack heroin users co-inc id ing wi th a great expans ion of methadone maintenance programs — for main ly whi te “pat ients .” 61 These rac ia l double s tandards resul t in heal th inequi t ies , f rom the doctor ’s off ice , to how law is enforced, to how people wi th drug addict ion are t reated. POLITICAL APPROACHES

W ith Pres ident Trump’s announce-ment in October 2017 of the epidemic being a nat ional publ ic heal th emergency, 62 there was a fami l iar Reagan era mora l i s t ic tone: respons ib le c i t i zens should absta in f rom the ev i l s of drugs under a l l c i rcumstances and “Just Say No.” L ike the Nancy Reagan campaign of 1980’s , th is not only i s ineffect ive 63

but i t undermines how and why people are us ing opioids in the f i rs t

AN INTERDISCIPLINARY PERSPECTIVE ON THE OPIOID CRISIS (CONT.)by Elena Roemer, DACM Candidate

place .2 However, Pres ident Trump did ment ion of some publ ic heal th measures : l ike access to rehabi l i -tat ion programs, funding research for non-addict ive pain medicat ion, requi r ing more t ra in ing for pre-scr ibers of these medicat ions , and increas ing ava i labi l i ty and com-munity t ra in ings for Naloxone, a harm reduct ion medicat ion used to reverse overdose. Whi le there has been skept ic ism on i f these prom-ises can take effect 64, the adminis-t rat ion’s two-year budget proposes to a l locate a substant ia l amount of resources into research, prevent ion, and t reatment serv ices . However, i t a lso a ims to cut government fund-ed heal th insurance programs l ike Medicare and Medica id, leav ing many wi thout coverage. 65

The Trump administ rat ion has a lso made i t very c lear that they are tak ing a s t rong puni t ive cr iminal just ice approach to the cr is i s . In Pres ident Trump’s more recent speech regarding the cr is i s , he declared that those prosecuted t ra ff ick ing opioids are deserv ing of capi ta l punishment and pra ised Pres ident Rodr igo Duterte of the Phi l ippines for hav ing taken a s imi lar approach 66 This i s radica l -ly d i fferent f rom moving towards a publ ic heal th approach. This i s especia l ly t rue wi th Attorney Genera l Jeff Sess ions at the helm of the Department of Just ice, who has a h is tory of rac ia l ly host i le comments and vot ing record 67, as wel l as recent ly re instat ing longer sentences for drug prosecut ions . 68 As h is tory has shown 57, un less s ig-n i f icant changes are made wi th in the nat ion’s cr iminal just ice system, th is puni t ive approach wi l l l i ke ly not so lve the problem but cont inue to resul t in d isproport ional ly more POC incarcerated. A radica l publ ic heal th resolut ion is decr iminal i zat ion. Both the Wor ld Heal th Organizat ion 69 and Uni ted Nat ions 70 have advocated for th is approach. This fo l lows the major successes of Portugal ’s decr iminal -i zat ion and publ ic heal th campaign of 2001, decr iminal i z ing drug use and expanded i ts publ ic heal th effor ts to more compass ionate ly help addicts . The Heal th Minis t ry of Portugal est imates that 25,000 Portuguese current ly use heroin , down f rom 100,000; and the opioid overdose rate has decreased 85% s ince the pol icy began. 71 Whi le drug dealers cont inue to be sen-tenced to pr ison, when someone is found wi th a personal possess ion of drugs, they are instead sent to a meet ing wi th soc ia l workers who prov ide resources for addict ion and

24

mental heal th support . Another important part of the publ ic heal th campaign is the government- fund-ed outreach vans , which make rounds on the st reets of Portugal g iv ing out f ree methadone to a l low addicts to gain s tabi l i ty instead of re ly ing on st reet heroin . 71 The cr is i s in the Uni ted States i s fundamen-ta l ly d i fferent f rom Portugal , as i t d id not s tar t f rom over-prescr ip-t ions . However th is serves as coun-t ry a model in how harm reduct ion and publ ic heal th effor ts work . INTEGRATIVE MEDICINE AND PUBLIC HEALTH

I t i s un l ike ly the Uni ted States wi l l be tak ing a decimal izat ion ap-proach to the current opio id cr is i s . Instead the push must cont inue to be on a l locat ing resources into publ ic heal th measures to see any far reaching and equi table changes in th is opio id cr is i s . Moreover, a decis ive way for pat ients to get the improved care for pain and addic-t ion is hav ing integrat ive medi-c ine fused into these programs. Once informed of the benef i ts of integrat ive medic ine l ike acu-puncture, pat ients most of ten do not choose use these modal i t ies because of cost barr iers . 52 Many integrat ive medic ine intervent ions are ev idenced-based and would be powerfu l complements to current programs or those being craf ted to meet the needs of the cr is i s . Some examples of th is could be acupunc-ture offered at more Methadone c l in ics and f ree needle exchange s i tes , or integrat ive medic ine offered as part of county menta l heal th fac i l i ty programs. The in-c lus ion of Integrat ive Medic ine as i t ’s own department in pr imary care sett ings would make i t easy for pa-t ients coming in for pain manage-ment to access these serv ices , l ike at Ka iser Oakland 72, or in hospi ta ls l ike Highland Hospi ta l in Oakland, Cal i forn ia . 73 Addit ional research is c r i t ica l to cont inue bui ld ing the ev idence base for these modal i -t ies , part icu lar ly herbal medic ine. 74 W ith the a l locat ion of resources for researching t reatments for addic-t ion and non-addict ive therapies for pain , now is an excel lent t ime to fund research on integrat ive medic ine approaches. 65 Pract i -t ioners a l ready offer ing access ib le t reatments , l ike community s ty le acupuncture might be able to apply for s tate grants to cont inue offer ing these serv ices to support opio id dependent pat ients . A lso cr i t ica l i s advocat ing for acupunc-ture coverage and adequate prac-t i t ioner compensat ion by insurance companies , f rom both government

programs and pr ivate companies . Insurance coverage compels pa-t ients to use these serv ices when out-of -pocket expenses are min-imized. Advocates and lobbyists who st raddle the intersect ion of publ ic heal th and integrat ive med-ic ine are essent ia l for advancing these k inds of integrat ive solut ions at the upstream pol icy level . The current opio id epidemic echoes a recurr ing pattern through-out human h is tory : a phys io logica l suscept ib i l i ty to fa l l ing under the spel l of Papaver somni ferum and i ts der ivates . W ith an so many under th is spel l in the Uni ted States in the current cr i s i s , a l ternat ives to opio ids and solut ions for thei r s ide effects are needed. Integrat ive medic ine, l ike acupuncture and herbal medic ine, offers remark-able tools that can become an integra l part of pa in management and opioid addict ion solut ions . However, for these modal i t ies to be ava i lable to those who need them most , they must be part of la rger publ ic heal th pol ic ies a imed at prevent ion and access . Other countr ies l ike Portugal have shown that an approach based in publ ic heal th and compass ion can reduce the numbers of opio id re lated overdose deaths . 71 On the other hand, the puni t ive approach taken by the Uni ted States in past drug epidemics resul ted in exacerbat-ed rac ia l d ispar i t ies in heal th and in the cr iminal just ice system. 57, 75 Therefore as pol icy makers debate how to approach th is cr i s i s , at ten-t ion must be paid to which groups these pol ic ies serve and who is le f t wi th no opt ions . Pract i t ioners must work together to cont inue bui ld-ing the research base and creat ing inc lus ive programs to offer the best integrat ive medica l care to pat ients . U l t imate success could be measured in a number of ways inc luding: reduct ion of opiate over-dose deaths , successfu l t reatment of pa in wi th safe a l ternat ives , more people in addict ion recovery, im-proved equi table access to heal th-care, and res i l iency in communi-t ies . As pract i t ioners and pol icy makers come into a l ignment on how to address th is complex issue, compass ion is c r i t ica l in creat ing susta inable solut ions for those in desperate need.

REFERENCES

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www.cdc.gov/drugoverdose/data/prescr ib ing.html . Publ ished August 31, 2017. Accessed March 5 , 2018.

3 ) Abuse NI on D. Opioid Overdose Cr is is . ht tps : //www.drugabuse.gov/drugs-abuse/opioids/opioid-over-dose-cr is i s . Publ ished March 6 , 2018. Accessed Apr i l 16 , 2018.

4 ) Pa lamar JJ , Dav ies S , Ompad DC, Cle land CM, Weitzman M. Powder Cocaine and Crack Use in the Uni ted States : An Examinat ion of R isk for Arrest and Socioeco-nomic Dispar i t ies in Use. Drug Alcohol Depend. 2015;149:108-116. doi :10 .1016/ j .drugalc-dep.2015.01.029

5) Zez ima K. Pres ident Trump suggests execut ing drug deal -ers at summit on opioid cr is i s . Washington Post . ht tps : //www.washingtonpost .com/nat ional/t rump-suggests-execut ing-drug-dealers-at -summit-on-opioid-cr i -s is/2018/03/01/58f1ec4c-1d98-11e8-ae5a-16e60e4605f3_story.html . Publ ished March 1 , 2018. Accessed Apr i l 12 , 2018.

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AN INTERDISCIPLINARY PERSPECTIVE ON THE OPIOID CRISIS (CONT.)by Elena Roemer, DACM Candidate

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AN INTERDISCIPLINARY PERSPECTIVE ON THE OPIOID CRISIS (CONT.)by Elena Roemer, DACM Candidate

Elena Roemer i s pass ionate about integrat ive menta l heal th and mak-ing medic ine more access ib le . She received her degree at UC Santa Cruz and whi le s tudying west-ern herbal ism and enthnobotany. E lena is a pract ic ing herbal is t and wel lness coach based in Oakland, Cal i forn ia , and wi l l be complet ing a doctorate in acupuncture and Chi -nese Medic ine in Fa l l 2018.

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ABSTRACT

In th is ar t ic le , I int roduce a formula that I have found very usefu l over the years in my herbal pract ice: Cinnamon Twig wi th Oyster Shel l and Foss i l i zed Bone, or Gui Zhi J ia Long Gu Mu L i Tang , which I re fer to f rom here on out as Modi f ied Cinnamon Twig Formula . I a lso g ive an int roduct ion to a t radi t ion of Chinese herbal pract ice that i s at the heart of contemporary and c las-s ica l East -As ian herbal pract ice. I w i l l present the modern indicat ions for the formula and, through case examples , i l luminate some poss i -b le appl icat ions , some of which apply d i rect ly to the references in the text and others that re ly on my interpretat ion of c l in ica l f indings.

Modi f ied Cinnamon Twig or ig ina l ly appears in the Prescr ipt ions f rom the Golden Coffer, or J ing Gui Yao Lue , wr i t ten by Zhang Zhong J ing CE 220. Zhang Zhong J ing’s meth-ods of t reatment , out l ined in Trea-t ise on Cold Damage (Shang Han Lun) and in Prescr ipt ions f rom the Golden Coffer , emphas ize warm-ing and supplement ing therapies . Zhang Zhong J ing l ived in an era of intense famine and h is develop-ment and chronic l ing of th is system was in part a react ion to what he perceived to be deleter ious t reat-ment of d isease wi th purgat ion therapies . LEARNING OBJECTIVES

To int roduce and explore the use of Modi f ied Cinnamon Twig Formula as a method for t reat ing var ious ex-press ions and or ig ins of post- t rau-mat ic s t ress d isorder (PTSD) and substance abuse, both together and separate ly. INTRODUCTION

While I have studied and used th is formula for years , my interest in i t was inv igorated around e ight years ago when I began studying the works of Zhang Zhong J ing wi th Dr. Arnaud Vers luys through the Inst i tute of Class ics in East As ian Medic ine and received a thorough explanat ion of i ts or ig ins and inc lu-s ion in J in Gui Yao Lue . Over the fo l lowing years , I began to observe a few common patterns in indiv idu-a ls for whom th is formula appeared to be st rongly indicated. These ob-servat ions were based on t radi t ion-a l methods of inqui ry in East -As ian medic ine, inc luding pulse and abdominal pa lpat ion, const i tut ional assessment v ia observat ion of habi -tus , and a s tandard inqui ry of body funct ions .

I began to see common denom-inators of d i fferent express ions of post- t raumat ic s t ress d isorder, of ten as sequelae of sexual abuse, substance abuse wi thdrawal , a h is tory or concurrent use wi th psycho-pharmaceut ica ls or i l legal narcot ics seeking harm reduct ion,

and states of e i ther sexual hypo- or hyper-arousal , usual ly consc ious ly l inked to abuse, substance abuse patterns , or both. The cont inui ty of re l ie f that Modi f ied Cinnamon Twig Formula brought about f rom both acute and chronic suffer ing has led me to bel ieve that th is i s a very va luable tool when used appropr i -ate ly for prov id ing support to indi -v iduals exper ienc ing these forms of imbalance.

One of my main object ives , as wel l as my hope and intent ion, i s that readers wi l l f ind these methods usefu l in re lat ion to thei r ex is t ing pract ice and that they might be mot ivated to s tudy East -As ian herb-a l medic ine to learn the context in which th is formula i s t radi t ional ly appl ied. My secondary a im in present ing these cases and th is formula i s to int roduce the concept of har-monizat ion to audiences of West-ern-t ra ined herbal is ts and heal th-care prov iders who may be aspi r ing to offer herbs to pat ients and are explor ing a var iety of paradigms wi th in which to do so. HARMONIZATION IN TCM

‘To harmonize’ i s def ined in A Pract ica l Dict ionary of Chinese Medic ine as ‘To coordinate one e lement of the body wi th the rest of the body or to coordinate two e lements of the body. ’ 1 Th is can refer to harmoniz ing organs in d is -harmony wi th the rest of the body, organs in d isharmony wi th each other, or the reharmonizat ion of phys io logic phenomenon unique to Chinese medic ine, such as harmo-niz ing construct ive and nutr i t ive aspects of the body or harmoniz ing lesser yang. Each of the cases below exhibi ts unique ways in which the formula in quest ion embodies pr inc ip les of harmonizat ion. In part icu-lar, th is i s an example where the body is being supplemented and st rengthened whi le the mind and nervous system are being sedated and ca lmed. A s impl i f ied descr ip-t ion that Western herbal is ts may cons ider analogous would be the concurrent use of adaptogenic or var ious ‘ tonic ’ herbs for bui ld ing st rength and nerv ines or sedat ives to re lax and ca lm the mind and/or the nervous system as i t integrates wi th speci f ic organs. As th is ar t ic le may reach a d iverse audience of herbal pract i t ioners , i t i s my intent ion to offer tools and ins ight into methods that I have found usefu l in br inging re l ie f of suffer ing. These methods ut i l i ze a d iagnost ic f ramework that i s over 2000 years o ld and tools to br ing about re l ie f or resolut ion of d ishar-monies in mult ip le body systems, which may not be t reated concur-rent ly in other medica l or heal ing f rameworks . I recognize that i t

DISCUSSIONS ON GUI ZHI JIA LONG GU MU LI TANG: APPLICATIONS FOR TREATMENT OF TRAUMA AND SUBSTANCE ABUSE Benjamin Zappin, L .Ac.

can be problemat ic to break f rom t radi t ion, as I am doing, and I hope that readers wi th s t rong convict ions about such matters wi l l be pat ient and recognize my interpretat ions for a broader audience, which may br ing about more a l lev iat ion of suffer ing. In part icu lar, i t i s import -ant to acknowledge that tak ing bi ts and pieces f rom t radi t ional systems wi thout a broader context for appl i -cat ion may lead to in jury of the pa-t ient or no recourse for eva luat ion of the therapeut ic methods when they do not work .

INDICATIONS

Zhang Zhong J ing f i rs t d iscusses Modif ied Cinnamon Twig Formula in the Blood Impediment and Vacui ty Taxat ion sect ion of the J in Gui Yao Lue, or Essent ia l Prescr ipt ions f rom the Golden Cabinet . The or ig ina l s igns emphas ized are seminal loss wi th s t r ing- l ike tens ion in the lesser abdomen, y in head-cold, ha i r loss , seminal loss for men, and dream-ing of intercourse in women. The pulse descr ibed is “sca l l ion sta lk ,” s t i r r ing, and s l ight ly t ight . Modi f ied Cinnamon Twig is cat -egor ized in modern formular ies under ‘Formulas that Secure and Astr inge’ and is pr imar i ly indicat-ed for rest ra in ing incont inence of ur ine and semen. The formula i s a lso used for menta l /emot ional imbalances, part icu lar ly when there i s an intersect ion wi th urologica l or gynecologica l compla ints . Modern l i s ts of indicat ions inc lude: tens ion in the lesser abdomen, excess ive sexual dreams, seminal leakage, cold in the head of the penis , im-potence, insomnia wi th excess ive dreams, bed-wett ing in ch i ldren, d izz iness , pa lp i tat ions , forget fu l -ness , neuros is , ha i r loss , occas ion-a l watery d iar rhea, genera l i zed weakness in phys ica l s t rength and condit ion, cold body, n ight sweats , a f loat ing pulse, and muscle aches. The presence of any of the above symptoms or s igns should point the pract i t ioner to cons ider Modi f ied Cinnamon Twig Formula as part of the t reatment p lan. There are severa l s igns and symp-toms that occur in the source text and other commentar ies on the formula that I have found to can be usefu l in interpret ing whether th is i s an appropr iate for a g iven pat ient . Severa l of these wi l l be explored throughout the case h is -tor ies presented below. INGREDIENTS AND ACTIONS C innamon twig (gui zh i ) 9g White Peony root (ba i shao) 9g Fresh Ginger root ( sheng j iang) 9g L icor ice root (gan cao) 9g Jujube date (da za ) 12 p ieces Foss i l i zed bone ( long gu) 9g Oyster shel l (mu l i ) 9g

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The formula i s t radi t ional ly pre-scr ibed as a decoct ion, and the above dosages are those used for a dai ly dosage, three t imes per day. The formula i s current ly ava i lable in the Western market in powdered extract and pi l l form as wel l .

Modi f ied Cinnamon Twig uses the base formula , Cinnamon Twig De-coct ion, to gent ly warm and nour ish the body when i t i s necessary to harmonize the inter ior and exter i -or of the body. This occurs in the inc idence of colds and f lus where the body has insuff ic ient resources to expel an external ly contract -ed pathogen, thus fac i l i tat ing a warm diaphores is . The addit ion of foss i l i zed bone and oyster shel l ast r inges f lu ids , ca lms and sett les the mind, and ass is ts the formula in harmoniz ing the ascending and descending of q i and f lu ids in the body. In th is case, the yang qi of the k idneys fa i l s to rest ra in the f lu ids of lower or i f ices , resul t ing in leakage of water through the bowel , ur ine, and semen. At the same t ime, the f lu ids unchecked cannot rest ra in the yang qi , which ascends and creates a scenar io in which empty heat a ffects the mind, caus ing agi tat ion and excess ive dreaming. Cinnamon twig warms the yang or v i ta l energy of the body whi le peony rest ra ins and nour ishes the y in , or substant ia l f lu id aspect of the body. The func-t ions of these herbs both support and at tenuate each other ’s effects . Ginger and ju jube date support the nour ish ing aspect of the ch ief in-gredients , whi le l icor ice harmonizes the act ions of the other herbs in the formula . In addit ion to ca lming agi tat ion and sett l ing the mind, foss i l i zed bone and oyster shel l as-t r inge leakage of sweat , ur ine, and semen. As ev ident in the cases , the formula i s of ten fur ther modi f ied to emphas ize t reatment of var ious aspects of the presentat ion.

CASE STUDIES

Case #1

Nei l i s a pat ient I have t reated a lmost every week for the past s ix years , pr imar i ly wi th acupunc-ture. He came to me a couple of years ago wi th an acute head-cold accompanied by copious s inus dra inage and conf ided to me that he was coming down f rom a 48-hour methamphetamine binge af ter seven years of sobr iety ( fo l lowing 20-plus years of chronic metham-phetamine and crack abuse) . He was very anx ious and descr ibed h is drug abuse h is tory as “re lated to patterns of sexual compuls ion that s tem f rom sexual abuse as a ch i ld” and that in th is b inge he had in-dulged such behaviors and “wasn’t d issat is f ied wi th the resul ts .” Upon inqui ry, Nei l reported feel ing very cold wi th t ight neck and shoulders , n ight sweats , and h is s tools were qui te loose. He hadn’t s lept in 48 hours and was exper ienc ing palpi -

tat ions . His pulse was f loat ing and weak and upon abdominal pa lpa-t ion exhibi ted pulsat ions in the midl ine and below the navel . Nei l i s a lso HIV-pos i t ive and l ives in a neighborhood that he descr ibes as “tak ing 5 years to grow accustomed to the amount of v io lence.”

Nei l ’s presentat ion has indicat ions of both the Modi f ied Cinnamon Twig decoct ion and the base for-mula , Cinnamon Twig decoct ion. I gave Nei l f i ve packets of the formula modi f ied wi th 9g of kudzu (ge gen) to address the loose stools , t ight neck and shoulders , and congest ion then inst ructed h im to make one bag every day. Upon complet ion of the in i t ia l course of herbs he appeared much more ca lm and rested. He reported h is bowel s tabi l i z ing and h is head cold abat-ing, wi th reduced crav ings for sex and drugs. He a lso reported feel ing more energized and warm, and h is n ight sweats and palpi tat ions had ceased. The pulse was s t i l l weak but no longer f loat ing, and the abdominal pulsat ions had reduced cons iderably. He and I agreed that th is formula su i ts h is const i tut ion wel l and he cont inued to take the formula , wi th the kudzu removed, mult ip le days a week for severa l weeks . Later, he reported that i t he lps support a more rest fu l s leep, reduces menta l agi tat ion, and that i t reduces h is crav ings and ideat ion about drug use.

Nei l ’s acute exacerbat ion of th is presentat ion - a part icu lar ly exag-gerated example of excess ive sexu-a l act iv i ty - i s a pr imary et io logy of the disease according to the source text . In combinat ion wi th the use of very deplet ing substances helped to put both h is const i tut ion and some of the aspects of h is imbal -ance under the microscope. His in-somnia and menta l agi tat ion, n ight sweat ing, and palpi tat ions are the main express ions of the def ic ient y in leading to yang ascending. His sensat ion of bodi ly cold, f requent ur inat ion, and loose stools were the main express ions of weak yang los ing contro l of y in . Case #2

V iv ian was three-months postpar-tum fo l lowing a d i ff icu l t pregnancy and f ragi le neonata l exper ience for both mother and chi ld . In ear ly Jan-uary she began to have panic at -tacks dur ing which she exper ienced ampl i f ied ideat ion of the death of her new baby. Dur ing the at tacks she would become immobi le and cry inconsolably, inc luding whi le s tanding, remain ing uncommunica-t ive wi th her spouse for hours . She descr ibed her body as very cold and “f rozen” dur ing the at tacks , and that th is fur ther esca lated her sense of help lessness and fear. She exper ienced f requent ur inat ion and n ightt ime ur inat ion, but suffered no hai r loss . When I f i r s t received a ca l l about th is I recommended that

DISCUSSIONS ON GUI ZHI JIA LONG GU MU LI TANG: APPLICATIONS FOR TREATMENT OF TRAUMA AND SUBSTANCE ABUSE (CONT.)Benjamin Zappin, L .Ac.

they use a preparat ion of Western Pasquef lower (Anemone occ identa-l i s )7 , Cal i forn ia Poppy (Eschscholz ia ca l i forn ica ) , Cal i forn ia Skul lcap (Scute l lar ia ca l i forn ica ) , and Kava Kava (P iper methyst icum) . This seemed to abate the symptoms and poss ib ly br ing the in i t ia l round of at tacks to a ha l t rather quick ly.

I have seen th is grouping of herbs work effect ive ly in numerous severe psycho-emot ional c r i ses and f ind i t p laus ib le that i t was indeed respon-s ib le for s tabi l i z ing the pat ient . I do not bel ieve that th is grouping of herbs has the potent ia l to ad-dress the under ly ing const i tut ional imbalance of th is or other cases ment ioned. I bel ieve they have the potent ia l to be used in formula wi th addit ional herbs to address the root imbalance, a l though that d iscuss ion is beyond the scope of th is ar t ic le .

I then prescr ibed a var iat ion of Modi f ied Cinnamon Twig wi th the addit ion of sprouted wheat ( fu x iao mai ) . Sprouted wheat , a long wi th l icor ice and ju jube date, adds the indicat ions of L icor ice, Wheat , and Jujube Combinat ion (Gan mai da zao tang ) to the formulas . These indicat ions inc lude f requent cry ing spel ls . A month e lapsed between the in i t ia l prescr ipt ion and her con-f id ing that she had not taken the formula and was cont inuing to have a d i ff icu l t t ime. She let me know that she had begun to process her own sexual abuse h is tory, that i t was at the root of her breakdowns, and that she was act ive ly in therapy for i t . I had a l ready begun wr i t ing th is ar t ic le and forming impress ions of the va lue of Modi f ied Cinnamon Twig in the t reatment of PTSD and sexual t rauma and chose to te l l her about i t , which prompted her to take the herbal prescr ipt ion more ser ious ly. At of the t ime of th is ar-t ic le , she has been on the formula for seven days , tak ing a bag of tea per day cons is tent ly, and she reported that she immediate ly fe l t substant ia l ly more t ranqui l , warm, and supported s ince commenc-ing to take the decoct ion and is enthus iast ic about cont inuing wi th i t . V iv ian i s a somat ic integrat ion therapist and expressed that the formula has a l lowed her body to be a more “comfortable conta iner for some of the complex emot ions and exper iences I have been v is i t ing.”

I th ink i t i s important to cons id-er the associated s ign, “women dreaming of intercourse” f rom the source text as an important guide for appl icat ion of th is formula for sexual t rauma that remains a source of d iscomfort for the indiv idual of any gender. I a lso bel ieve i t i s usefu l to c i te the “bi r th as being analogous to the blood loss” et io l -ogy l i s ted in the source text for the formula . Anxiety, panic at tacks , and intense fear fu lness account for the ascending def ic iency yang in the symptom picture, and the contract -

30

ing coldness a long wi th f requent ur inat ion is indicat ive of yang def i -c iency cold.

Case #3

Rick i i s a 24-year o ld female whose chief compla ints are anx iety, f re-quent ur inat ion, n ightt ime ur ina-t ion, and occas ional incont inence. She has a h is tory of sexual t rauma and reports hav ing f requent ide-at ion of th is t rauma that i s d is rup-t ive to her dai ly l i fe . She c la ims to have loose stools when she doesn’t eat a ce l iac d iet , which she tends to not adhere to very wel l . The pat ient had a very d i ff icu l t t ime making eye contact in the in i t ia l sess ion and seemed very s tar t led every t ime she spoke. I saw her in an integrated c l in ic , so I had access to the background of her case in chart notes f rom other phys ic ians , inc luding abuse h is tory, counsel ing status , and recommendat ions she received for natura l therapies that were out of her pr ice range. This in format ion enabled me to do a fa i r ly e ff ic ient intake wi th someone who was admit tedly uncomfortable speaking. I t a lso enabled me to have a c lear p icture of the abuse h is tory wi thout hav ing to probe for a s tory. She a lso reported coldness , low energy, and scant menstrua l per iods. Pulsat ions in the midl ine of the abdomen and pulsat ions be-low the navel were very s t rong and forcefu l , and her pulse was weak and f loat ing. R ick i was d ispensed seven bulk packets of Modi f ied Cinnamon Twig Decoct ion and consumed these over two weeks . Upon seeing her for the f i rs t return appointment she was very exc i ted and eager to share her progress . She was much more luc id and ar t icu late than dur ing our f i r s t meet ing and descr ibed feel ing much more energy, warmth, and conf idence in communicat ing wi th others . She reported spend-ing a lot less t ime in ideat ion about her t rauma. She shared that she had not had any episodes of incont inence and that her ur inary f requency had great ly d imin ished. Her pulse was s t i l l weak and hol low, and her abdominal pulsat ions were reduced in s t rength. I have s ince cont inued her on the formula for severa l months , which she takes wi th a s imi lar cons is tency. She states that i t cont inues to support her in the ways descr ibed above.

I bel ieve that the et io logy of th is case is re lated to the symptom in the source text of excess ive dreams of sexual intercourse, which mani fests as cont inual ideat ion of sexual t rauma. This case i l lust rates c lear ly the pr imary contemporary appl icat ion of the formula of ‘ se-cur ing and ast r inging the ur ine’ . Many herbal is ts and phys ic ians wi l l note that th is can be an extremely d i ff icu l t problem to t reat and that the formula ic method for resolv ing the ur inary problem is very d i ffer-

ent that those commonly employed, usual ly involv ing the use of sour, ast r ingent herbs . The compl icat ion of loose stools can a lso be inter-preted as a descent of substances due to unsecured yang. Her con-fus ion, lack of focus , and f requent ideat ion of her t rauma are a l l c lear s igns of ascending yang due to lack of y in .

DISCUSSION

Two common denominators found throughout these three cases indicate that Modi f ied Cinnamon Twig is an appropr iate formula for s t rong pulsat ions f rom the base of the sternum to the umbi l icus and pulsat ions just below and to the s ide of the navel . These are not modern indicat ions for th is formula but rather are indicat ions f rom the Japanese herbal t radi t ion ca l led Kampo. Pulsat ions above the navel in the midl ine are an indicat ion for the use of c innamon and oyster shel l , whi le pulsat ions below the navel are an indicat ion to use fos-s i l i zed bone, according to the 17th century Japanese scholar Yakucho. Ear ly Kampo scholars are famous for hav ing uni ted the pract ice of Fukushin , or abdominal pa lpat ion, wi th the works of Zhang Zhong J ing, where i t cont inues to be ut i -l i zed in Japan’s nat ional heal th care system.

For the Western herbal is t who is d is inc l ined to use Chinese herbal medic ine, I fee l i t i s va luable to extract the therapeut ic pr inc ip le of harmonizat ion f rom these cases and formulas . I t i s not d i ff icu l t to recreate formulas that are warming, inv igorat ing, and ascending that s imultaneous ly cool , re lax , and de-scend agi tated menta l s tates ut i l i z -ing herbs domest ica l ly produced or wi ld-harvested. Most of the herbs in the base formula Cinnamon Twig Decoct ion have a l ready been commonly adopted into Western herbal pract ice for decades or even centur ies . Cinnamomum, Glycyr-rh iza , and Z ingiber is are a l l p lants that are commonly ava i lable here in the West . Paeonia i s widely ava i l -able , though may not be as fami l iar to some. WESTERN PLANTS USEFUL AS POTENTIAL MODIFICATIONS:

Palpi tat ions : Motherwort (Leonurus cardiaca ) + Western Pasquef lower (Anemone spp) W ind- damp pain and st i f fness : Kava (Piper methyst icum ) + Black Cohosh (Actaea racemosa )

W ithdrawal , s t i f fness , and pain : Kava (Piper methyst icum ) + Pedicu-lar is (Pedicular is sp . )

Urogeni ta l d iscomfort and cold-ness : Western Pasquef lower (Anem-one spp )

Substance use wi thdrawal ( in con-

junct ion wi th const i tut ional sup-port ) : Rx medicat ion: Verva in (Verbena off ic ina l i s ) + Skul lcap (Scutel lar ia later i f lora ) Amphetamines and psychedel ics : Western Pasquef lower (Anemone spp ) , Skul lcap (Scutel lar ia later i f lo-ra ) , Cal i forn ia Poppy (Eschscholz ia ca l i forn ica ) , Hawthorn (Crataegus sp. ) A lcohol : Kudzu (Puer ia lobata ) CONCLUSION

By v i r tue of these three examples , I th ink that wi th an appropr iate presentat ion, Modi f ied Cinnamon Twig Formula i s an important for-mula to look at in cases of PTSD. I have prescr ibed th is formula for severa l other pat ients who present wi th a s imi lar p icture and report a h is tory of sexual or other t rauma, inc luding those who have found the l imits of Western psychiat r ic pharmaceut ica ls and var ious forms of counsel ing. As pat ients may not a lways conform exact ly to the patterns that are s tudied, i t i s the respons ib i l i ty of the pract i t ioner to interpret f indings and corrobo-rate wi th the perspect ive of other phys ic ians . By no means should the reader interpret th is to mean that th is i s a ‘go-to’ formula for PTSD, but rather, i t i s meant to be an example of how studying the language of c lass ica l text f rom var ious condit ions and e l ic i t ing the correct interpretat ion, we can of ten f ind solut ions to common biomedi-ca l ly -def ined compla ints that have only re lat ive ly recent ly been used to def ine var ious phenomenon of the human exper ience. Regardless of your herbal prescr ib-ing procl iv i t ies , i t can be of great ut i l i ty to s tudy sty les wi th archaic roots that cont inue to f ind expres-s ion in modern medica l systems. In the case of th is formula , the precedent ex is ts in a text that i s 1800 years o ld and i t i s a current ly prescr ibed in the medica l systems of severa l East -As ian nat ions . I t i s my intent ion that th is ar t ic le serves as a br idge to readers tak ing in-terest in the formula i tse l f and the therapeut ic pr inc ip les i t embodies , as wel l as the formula ic s ty le of Zhang Zhong J ing.

REFERENCES

1) W iseman N, Feng Y. A Pract ica l Dict ionary of Chinese Medic ine. Taos, NM: Paradim Publ icat ion; 2014.

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“SHEN-OCIDE”: TREATING THE PSYCHOSPIRITUAL ASPECTS OF OPIOID ADDICTION WITH ACUPUNCTURE AND CHINESE MEDICINEMary E l i zabeth Wakef ie ld,L .Ac. ,M.S. ,M.M. ,Dipl .Ac. ,NCCAOM

ABSTRACT

“Shenocide” is a coined word, para l le l ing in s t ructure the more fami l iar genocide, an Engl ish de-r ivat ive of the or ig ina l Greek word “genos”, which means race. Geno-c ide is def ined as the “del iberate k i l l ing of a large number of people f rom a part icu lar ethnic group or nat ion.” 1

In contrast , shenocide, the k i l l ing of Shen spi r i t , i s not necessar i ly perpetrated by one group of indi -v iduals upon another of a certa in ethnic i ty. However, opio id addic-t ion, which effect ive ly destroys the pat ient ’s sp i r i tua l v i ta l i ty, i s re-spons ib le for a growing number of deaths wor ldwide. Opioid addic-t ion has reached epidemic propor-t ions in the Uni ted States . Here are some re levant s tat is t ics :

- In 2011, an est imated 4 mi l l ion people in the US used opioids recreat ional ly and were addicted to them. 2

- 23 mi l l ion Amer icans needed t reatment for addict ion in 2012, and only 2 .5 mi l l ion actual ly re-ceived t reatment . 3

- Close to 38 mi l l ion people used

opioids i l legal ly in 2013 4, and the number cont inues to grow!

In th is ar t ic le , we wi l l focus on the psychospi r i tua l imbalances that re-su l t f rom opioid addict ions , which are prec ip i tated by:

1 . Narcot ic drug prescr ipt ions for non-cancerous chronic pain , due to headaches, backache, f ibromyalgia , migra ines and nerve pain ;

2 . The r i se in misuse of i l legal rec-reat ional opio ids for thei r euphor ic effects .

As a pal l ia t ive for these addict ions , three suggested acupuncture pro-tocols for Shen dis turbances wi l l be int roduced, which can be integrat-ed into your acupuncture pract ice, in the context of a const i tut ional t reatment .

The author has employed a l l three t reatment protocols to good effect , not only for addict ions , but a lso to t reat Shen dis turbances resul t -ing f rom sexual , emot ional and spi r i tua l abuses , possess ion, PTSD (Post-Traumat ic St ress Dysfunct ion) and t raumat ic memory loss .

INTRODUCTION

Opioids are substances that are used medica l ly for both acute and chronic pain re l ie f , for revers ing opioid overdose, and for suppres-s ion of other symptoms. Some of the s ide effects of these drugs are :

• drowsiness• depress ion• euphor ia• ha l luc inat ions• compromised immune system• hormonal imbalances

Cont inuous use can foster depen-dency and to lerance to the drug; th is increases the need for h igher doses , and gives r i se to intense wi thdrawal symptoms, when i t i s d iscont inued. W ithdrawal symp-toms inc lude:

• severe dysphor ia• manic rav ing• depress ion• i r r i tabi l i ty• nausea, vomit ing, sweat ing• t remors and insomnia

Misuse of opio ids can cause severe psychologica l obsess ions , and contr ibute both to lack of judgment

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ous acc idents and/or death.

BACKGROUND

The word “opioid” hearkens back to the ear l ier drugs c lass i f ied as opiates , which are natura l ly der ived f rom the dr ied latex of the red pop-py (Papaver somni ferum ) , the pr in-c ipal one of which is opium, lachry-ma papaver is ( l i tera l ly, the “tears” of the poppy plant ) . His tor ica l ly, i t was one of the most popular drugs used for medica l , recreat ional and re l ig ious purposes. In the 3rd century BCE, the Sumer ians grew poppies and harvested opium f rom thei r seed pods, a l though the ear-l iest archaeologica l f inds of opium seeds date back to the Neol i th ic Era , approximately 5 ,000 years ago.

In 1804, Fr iedr ich W i lhelm Adam Sertürner, a German pharmacist , f i r s t i so lated morphine f rom the opium poppy, naming i t a f ter the Greek god of dreams, Morpheus. Short ly a f ter th is d iscovery, codeine was s imi lar ly i so lated f rom opium. In the 1850’s , the invent ion of the hypodermic needle made poss ib le the in ject ion of these and other substances into the body dur ing surgery, to address post-operat ive pain , and for genera l anesthes ia . A doctor could then give a pat ient a rapid dose of a des i red narcot ic ; for the recreat ional user, th is t rans-lated into the notor ious “quick f ix” of the drug addict .

Synthet ic morphine der ivat ives were formulated in the 20th cen-tury, and these substances were ca l led opioids , a word which means “opium-l ike.”

CHINESE MEDICINE VS. WESTERN MEDICAL

In Taoist phi losophy, the Three Treasures refer to three int r ins ic and inseparable forces that embody Heaven (shen ) , Humanity (qi ) and Earth ( j ing ) . In order to promote heal th , wel l -being and longevi -ty, i t was necessary to ref ine j ing into q i , q i into shen, and shen into openness . Th is was accompl ished in a t ransformat ive a lchemical pract ice of lac ing the three j i -aos w i th breath, meditat ion and acupuncture, and served to a l ign the pract i t ioner wi th t ian (Heaven) and the Source. Any mala ise , or an addict ion, was perceived as or ig i -nat ing in an imbalance in a l l three levels of being, and heal ing was approached f rom a hol is t ic per-spect ive.

In contrast , Western medic ine tends to target the pat ient ’s symp-toms. Consequent ly, as we have noted prev ious ly, drugs are f reely prescr ibed for chronic , non-can-cerous pain , for long-term use; th is indiscr iminate overmedicat ion can cause severe s ide effects and fac i l i tate eventual addict ion to the opioids .

S ince opioids have a sedat ive act ion upon the body, they can depress the funct ioning of the re-spi ratory system, caus ing pat ients to lapse into coma. I f taken to extremes, the heart wi l l s top, and death is the inev i table resul t . Th is scenar io i s more l ike ly to occur wi th recreat ional drug usage.

A recent t ragic case of opio id abuse is that of the unt imely pass ing of the rock s tar, Pr ince, who died, according to the off ic ia l autopsy report , f rom a se l f -admin-is tered dose of fentany l . Stor ies later emerged in the media of c landest ine v is i ts to pharmacies in the immediate v ic in i ty of h is Pa is ley Park compound in Minneapol is , l i kewise test i fy ing to h is s t rug-gles wi th intense pain in h is h ips brought about by h is onstage acro-bat ics in the youthfu l heyday of h is career. Pr ince’s weal th and fame made i t poss ib le for h im to gain un-rest r ic ted access to excess amounts of opio ids , and i t seems ev ident that he was addicted to them above and beyond h is need for re l ie f f rom his phys ica l d iscomfort . Pr ince a lso reported in interv iews that he had suffered f rom epi lepsy as a ch i ld , which is a ha l lmark of d is turbed shen, according to Sun S i Miao.

THE OLD CHINESE AXIOM: “THE SHEN LEADS THE QI”

The shen , through the medium of thoughts and emot ions , leads the f low of q i in our phys ica l being. Shen being ethereal in nature, i s not as dense as the body, and thus , wi th in th is corporeal vessel , i t can become stagnant . The associated emot ions , i f not expressed, lodge themselves in the cel l s , c reat ing a s tate of psychospi r i tua l tox ic i ty. I f th is sp i r i tua l b lockage is not moved through the act ion of the qi , then the person may seek something or someone to help them forget thei r longing and empt iness .

GUI: GHOSTS

Poney Chiang, Ph.D. , in an ar t ic le , Spir i ts , Ghosts and Chinese Medi-c ine , 5 re lates a fasc inat ing account of demonic possess ion, and how a speci f ic acupuncture point was ut i l i zed to expel a demon. Ap-parent ly, a Tu i -na doctor f rom China wi tnessed h is aunt exhib i t a superhuman abi l i ty, by which she leapt upon the roof of the house. This was fo l lowed by uncontro l lable dancing, as i f she were possessed by a mal ign spi r i t .

Her husband, a mart ia l ar ts inst ruc-tor, c l imbed up on the roof to br ing her down, however, she overpow-ered h im and threw h im off the roof wi thout any effor t . Due to the t remendous commotion, a crowd quick ly gathered, and speculated as to whether the doctor ’s aunt was possessed by a speci f ic demon.

After severa l other at tempts to

subdue her fa i led, the uncle was inst ructed by an unknown v i l lager to s t r ike h is aunt in her armpits . When he did so, she immediate ly col lapsed, and, upon regain ing consc iousness , she had no memory of the inc ident .

Dr. Chiang observes that th is point in the ax i l la could only have been H1, j iquan , Summit Spr ing, the entry point of the Heart mer id ian, and the abode of shen. For the gui to affect the shen, i t needed to invade the Heart . The pain that the possessed woman exper ienced f rom the st r ik ing of th is point caused the gui to depart and to return to i ts or ig ina l host .

This s tory could serve as a met-aphor for opio id addict ion, be-cause i t v iv id ly descr ibes the shen possess ion that i s so apparent in addict ive pat ients . Dr. Chiang a lso indicates that Ge Hong, the fa-mous Taoist a lchemist f rom the 4th century CE, used painfu l contact moxibust ion to t reat madness , rage and epi lepsy. Pa in was intent ional ly in f l ic ted on the body to resusc i tate the shen d is turbed pat ient , and to d ispel the gui/pathogen, which could be perceived in our era as an addict ion to heroin , opium, mor-phine or any opioid.

GUI: THE PERSONIFICATION OF THE SHADOW

Sun S i Miao (581-682 CE) , Taoist doctor and acupunctur is t f rom the Tang Dynasty, named ent i t ies which seek only mater ia l sustenance gui , or ghosts . These ent i t ies can be e i ther inher i ted predispos i t ions that we repeat throughout our l i ves wi thout any awareness of thei r source, or they can take the form of addict ions : opio id abuse, a lcohol-i sm, eat ing disorders , smoking, or any imbalance that impr isons the shen.

Gui can be regarded as the em-bodiment of the “dark” s ide of the human psyche, forces and dr ives that remain unconsc ious . They a lso can be personi f icat ions of a l l the haunted, suppressed qual i t ies that we have stashed away in our emot ional c losets – judged by us as being negat ive, wrong, in fer ior, scary or f r ightening. These forgot-ten shards of ourse lves have been shoved down “under the bel t” , only to emerge when abnormal s t resses or pressures mani fest to d is turb our dai ly l i ves – death, loss of employ-ment , d ivorce, etc .

I t i s then that the gui emerge f rom those deep recesses of our being, showing thei r faces to the l ight of day; these demons take contro l , mani fest ing as f r ight , fear, de-press ion, rage, and even mania . The shen is d is turbed and the gui searches for something to dampen the pain , and upl i f t the spi r i t . At th is t ime the euphor ic effect of opio ids may seem att ract ive to the suffer ing person.

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and dangerous behavior, i .e . , ser iJung would have regarded the gui as being synonymous wi th the shadow, because i t represents a l l the orphaned, d isembodied, re ject -ed aspects of ourse lves .

Giovanni Macioc ia has observed 6 that the Chinese characters for both the Hun, the Ethereal Soul , and the Po, the Corporeal Soul , conta in the radica l for gui , and that these souls are independent of the mind. In my opin ion, th is means that humanity possesses f ree wi l l , or a choice as to how they l ive thei r l i ves . However, whi le the path of opio id use may or ig inate in consc ious choice, th is addict ion eventual ly robs the person of thei r capaci ty to choose, s t r ipping them of thei r d igni ty. They are not in contro l of thei r impulses , and the demons take hold of the “dark forc-es” of the psyche.

GUI: THE 13 GHOST POINTS

I have used Sun S i Miao’s 13 Ghost points in my pract ice and have taught them to students in the Alchemical Level of the 2-year Internat ional GOLD STANDARD FA-CIAL ACUPUNCTURE® Cert i f icat ion Program at Northwestern Heal th Sc iences Univers i ty. I have a lso inc luded them in the curr icu lum of a course that I co-created wi th my partner, MichelAngelo, V ibrat ional Medic ine: 5 E lement Intergenera-t ional Patterns and GeneAstro lo-

gy™. The lat ter course ut i l i zes Acu-tonics® tuning forks on the points and mer id ians of the body, instead of needles . These points are ex-t remely effect ive when integrated into a const i tut ional t reatment , and address anyth ing that impr isons the spi r i t .

Sun S i Miao f i rs t documented these points in h is 7th century work , The Thousand Ducat Formulas . They re late to the removal of energet-ic b locks and emot ional f ixat ions , and a l lev iate symptoms of manic depress ion, epi lepsy, f r ight , b ipo-lar syndrome, menta l unrest and dis turbed Shen, a l l o f which are categor ized as forms of possess ion. The t reatments employ a combina-t ion of needles , moxa and bleeding techniques.

I do not recommend that the prac-t i t ioner use a l l 13 of the points in one sess ion, unless except ional c i rcumstances should indicate that they do so. I usual ly rotate 2 or 3 Ghost points in each sess ion, and integrate them into a const i tut ion-a l t reatment protocol , focus ing on anchor ing the yang qi and nurtur-ing the y in .

In my research, I d iscovered Sun S i Miao’s Ode to Needl ing the 13 Ghost Points , 7 t rans lated into En-gl ish . Apparent ly, the Ode rhymes beaut i fu l ly in anc ient Chinese, and prov ides an ample demonstrat ion of i ts author ’s knowledge, sk i l l ,

a r t i s t ry, and sense of humor. Sun S i Miao refer red to a “ghost ev i l” as a d isorder associated wi th demonic possess ion, and offered the fo l low-ing associated symptoms:

Seeing ghosts : delus ions of ghost-l ike imagery ; ha l luc inat ionsGhost ta lk : del i r ious speech, rant-ing and rav ingFloat ing ghost ta lk : menta l unrest , d is rupt ion of the spi r i tF loat ing corpse ta lk : del i r ium man-i fest ing dur ing the terminal s tages of tuberculos isMad Ghost walk ing: d is turbed s leep walk ing

Al l the Ghost points address these mani festat ions of d is turbed shen; some of them expel internal and external wind, restore consc ious-ness and c lear heat :

“SHEN-OCIDE”: TREATING THE PSYCHOSPIRITUAL ASPECTS OF OPIOID ADDICTION WITH ACUPUNCTURE AND CHINESE MEDICINE (CONT.)Mary E l i zabeth Wakef ie ld,L .Ac. ,M.S. ,M.M. ,Dipl .Ac. ,NCCAOM

A RARELY USED PSYCHOSPIRITUAL POINT: SJ 2, YEMEN, FLUID GATE

The second t reatment protocol in-volves SJ 2 , a y ing spr ing point that c lears heat f rom the upper body. I t could have been, in my opin ion, a 14th Ghost point , a l though there i s no reference to shen in i ts name.

I t i s usefu l in the t reatment of loca l pa in , heat and swel l ing of the back of the hand, wi th contracture of the f ive f ingers , re fer red to as DePuytren’s Syndrome. The San J iao mer id ian ascends to the head, the outer canthus of the eye, and enters the ear, therefore th is point a lso addresses t inn i tus , deafness , earache, headache and other symp-toms of heat imbalance. I t can a lso be very effect ive in the t reatment of Shen dis turbances.

Funct ions:

Moistens the mucuous membranes and regulates f lu ids in the upper bodyCalms heat and benef i ts the eyes and earsCalms the shen

Indicat ions:

Red and dry eyes and facePalpi tat ions , f rayed nerves , epi lep-sy, insomnia, shortness of breath, and psychospi r i tua l imbalances

SJ 2 i s the Water point on the F i re channel , and i t t ransports f lu ids to the face and head, which cools , moistens and ca lms th is area of the body. The San J iao exter ior/inter ior re lat ionship wi th the Per i -cardium, which wraps around and protects the Heart , the abode of shen, a l lows SJ 2 , yemen, to t reat a pat ient who is unable to “go wi th the f low”, one who lacks f lu id i ty in thei r l i fe .

For more ser ious psychospi r i tu-a l mani festat ions , such as manic depress ion, manic rav ing, ceaseless laughter or weeping uncontro l lably, I needle th is point in tandem with Sun S i Miao’s fourth Ghost point , P 7 , gui x ing, Ghost Heart .

This powerfu l combinat ion cools and moistur izes the head, face and s inuses , and c lears heat f rom the Heart , ca lming the shen.

A JAPANESE TREATMENT FOR OPIOID ADDICTION

This th i rd protocol was or ig ina l ly des ignated for opiate abuse, and addict ions that tox i fy and damage the Kidneys . The f i rs t point nee-dled is Japanese K 9 , zhubin, Guest House. In Grasping the W ind,8 i t i s expla ined that the radica l zhu means to “attack” and the radi -ca l b in means “to expel” , i .e . , the pathogen f rom the Kidneys .

Zhubin i s a x i -c lef t point which ad-

dresses emergency condit ions , and being a y in point , a lso t reats b lood and shen imbalances, because the blood ru les the shen. This makes i t a per fect point for manic de-press ion, fear, f r ight and chemical tox ic i ty that can ar ise f rom opioid addict ion.

K 27, shufu, Shu Mansion, i s the Kidney t ransport ing shu point , where the qi of the Kidney is col lected. I t i s a mans ion that abundant ly conta ins K idney qi and essence.

Indicat ions:

Long term addict ions , which dam-age the KidneysOpiate addict ion: opium, heroin , morphine, codeine and opioidsShen dis turbancesOveruse of s teroid hormonesOveruse of ant i - in f lammatory drugs

Needl ing Protocol :

Japanese K 9 , zhubin, i s 3 cun below K 10, y inggu. Needle K 9 perpendicular ly and bi latera l ly, or use di rect moxa.

K 27, shufu, i s needled bi latera l ly and t ransverse ly toward the Ren Mai , the sternum.

Reta in these needles in the body for the ent i re const i tut ional t reat-ment unless otherwise indicated.

CONCLUSION: A FEW INSIGHTS

“The non-medica l use of prescr ip-t ion drugs has been fueled by the medica l community ’s over- re l iance on the use of prescr ipt ion opioids to t reat both acute and chronic pain .” 9 Both medica l and non-med-ica l use of opio ids has esca lated in recent years , and addicts have now progressed to heroin and other drugs to “k i l l” phys ica l and psy-chospi r i tua l pa in . I t i s important for us , as acupunctur is ts , to col lab-orate wi th doctors , therapists and other heal thcare profess ionals in t reat ing and address ing th is para-lyz ing wound in our soc iety.

“We are representat ives of a med-ica l t radi t ion that has endured for thousands of years , that makes use of both logic and intu i t ive ins ight . Or ienta l medic ine is both an ar t and a sc ience; i t respects indiv idual d i fferences and the s igni f icance of speci f ic patterns or archetypal im-balances that may ar ise dur ing the course of t reatment .” 10

We know how to t reat imbalances of q i , addict ions and f ixat ions on both the phys ica l and psychospi r i -tua l levels , and can compass ionate-ly educate pat ients about change, choice and the poss ib i l i ty of heal -ing and t ransforming thei r l i ves .

REFERENCES

1) Oxford Engl ish Dict ionary. Ox-ford Univers i ty, 2013, pp. 379-80.

2 ) Report I I I : FDA Approved Medi-cat ions for the Treatment of Opiate Dependence: L i terature Rev iews on Effect iveness & Cost- Effect iveness , Treatment Research Inst i tute”. Ad-vancing Access to Addict ion Medi-cat ions : Impl icat ions for Opioid Ad-dict ion Treatment . p . 41 . ; accessed 1/10/18.

3 ) Tetraul t , Jeanette M. ; Butner, Jenna L . (2015-09-03) . “Non-Med-ica l Prescr ipt ion Opioid Use and Prescr ipt ion Opioid Use Disorder : A Rev iew”. The Yale Journal of B io l -ogy and Medic ine. 88 (3 ) : 227–233; accessed 1/10/18.

4 ) “Status and Trend Analys is of I l -l ic t [ s ic ] Drug Markets” . Wor ld Drug Report 2015; accessed 1/10/18.

5 ) Poney Chiang, “Spi r i ts , Ghosts and Chinese Medic ine. Or ienta l Medic ine Journal , New Year edi -t ion, January, 2008, 25-31.

6 ) Macioc ia , Giovanni , The Psyche in Chinese Medic ine: Treatment of Emot ional and Menta l Disharmo-nies wi th Acupuncture and Chinese Herbs. London: Churchi l l L iv ing-stone Elsev ier, 2009.

7 ) Dale , Ra lph Alan, Acupuncture: The Specia l Funct ion Points . North Miami Beach, FL : Dia lect ic Publ ish-ing Inc , 1996.

8 ) Andrew El l i s , Nigel W iseman and Ken Bass , Grasping the W ind: An Explanat ion into the Meaning of Chinese Acupuncture Point Names. Brookl ine, MA: Paradigm, 1989.

9 ) Tetraul t and But ler, op. c i t .

Mary E l i zabeth Wakef ie ld, L .Ac. ,M. S . ,M.M. , i s the internat ional ly rec-ognized author of the book, Const i -tut ional Fac ia l Acupuncture (E lse-v ier UK, 2014) . She has 30+ years of c l in ica l exper ience, and has personal ly t ra ined 5 ,000 heal thcare pract i t ioners f rom 5 cont inents .

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ABSTRACT

Research suggests acupuncture down-regulates in f lammat ion. But what are the mechanisms that dr ive th is process? In th is essay, I rev iew

studies about how inf lammat ion is regulated by the autonomic nervous system and studies that indicate acupuncture may act ive-ly part ic ipate in the regulat ion of in f lammatory cytok ines .

Keywords: Autonomic nervous system, immune regulat ion,

inf lammation, cytokines, acupuncture

CAN ACUPUNCTURE BIO-HACK THE AUTONOMIC NERVOUS SYSTEM AND DOWN-REGULATE INFLAMMATION? Dr. Sharon Hennessey, DAOM, L .Ac.

MAKING THE CASE: ACUPUNCTURE MODULATES THE AUTONOMIC NERVOUS SYSTEM

BLUE ARROWS SIGNIFY THE DOWN-REGULATING EFFECT OF ACUPUNCTURE.1

In the above i l lust rat ion, the blue l ines s igni fy the effects of acupuncture on an in f lammatory condit ion. Disorders such as s t ress , indigest ion, i r r i tabi l i ty, or pa in can indicate the effect of mi ld in f lammat ion.

Can ‘ the in f lammatory ref lex ’ which research indicates rebalances the autonomic nervous system be appl ied to the acu-puncture effect? Does the acupuncture t reatment act as a d is t r ibuted connect ion that a ffects both the autonomic nervous system and the immune system?

36

Recent s tudies indicate that heal th i s a del icate balance between the autonomic nervous system and cy-tok ine product ion. Overproduct ion of cytok ines can resul t in cr i t ica l and severe d isease such as seps is , rheumatoid ar thr i t i s , or u lcerat ive col i t i s . Research 1 indicates that by s t imulat ing the vagus nerve, cyto-k ine product ion can be dimin ished. Sensory input e l ic i ted by in jury or in fect ion t ravels a long the affer-ent branch of the vagus nerve to regions of the bra instem, and the bra in carr ies outbound s ignals that effect the spleen and other re-gions of the immune system. Some of research by Zhou 2 and Torres 3 suggests that acupuncture may down-regulate the immune system through the autonomic nervous system.

In an ar t ic le publ ished in 2000 4, Dr. Kev in Tracey in jected a chemical into a rat bra in , which act ivated the vagus nerve, resul t ing reduc-t ion of tumor necros is factor (TNF) throughout the body. In that same art ic le , the author descr ibes how in another such exper iment , Tracey in-jected endotoxin in a rat , a pro- in-f lammatory bacter ia l tox in typica l ly resul t ing in body wide in f lammat ion and seps is . He then e lectr ica l ly s t imulated the vagus nerve, reduc-ing TNF, thereby reducing inf lam-mat ion. He and other research sc ient is ts per formed a ser ies of exper iments on animal models 4, demonstrat ing that the vagus nerve when act ivated wi th e lect r ica l s t imulat ion affects the spleen’s deposi tory of immune cel l s . From there, David Fel ton, a neuroanato-mist captured microscopic images of hybr id neuron T-cel l s synapses, not only in the spleen, but thymus and lymph nodes which responded to sympathet ic t ransmiss ion. Ak iko

Nakai of Osaka Univers i ty reported T-Cel ls , a ffected by sympathet ic s t imulat ion ref ra ined f rom enter ing the wider immune system. 5 Lorton and Bel l inger 6 found that sympa-thet ic nerve pathways are modi f ied by immune disorders . There seems to be agreement by sc ient is ts that there i s no di rect neura l connec-t ion between the vagus nerve and spleen, but vagal s t imulat ion mod-ulates sympathet ic act iv i ty and the immune system. 5

The research, involv ing the au-tonomic nervous system, can be ut i l i zed by acupunctur is ts in both t reatment des ign and explanat ions about t reatment effect to doctors and pat ients . This essay rev iews some seminal research not only about how the autonomic nervous system interacts wi th the immune system, but s tudies that indicate a p lace for acupuncture in th is re-search that adjusts in f lammat ion in per iphera l t i ssues .

A BRIEF REVIEW OF THE VAGUS NERVE

The vagus nerve is the key com-ponent of the parasympathet ic system, compr ised of sensory and motor f ibers or a fferent and effer-ent pathways . The afferent port ion of the vagus nerve is far great-er – e ighty percent of the vagus. I t monitors autonomic act iv i t ies such as heart rate , b lood pressure, breath ing, d igest ion. Whi le the afferent port ion is re lay ing im-portant sensory in format ion to the bra in , the efferent f ibers , which are chol inergic , are act ivat ing parasym-pathet ic act iv i ty in the heart , lungs, l i ver, s tomach and upper port ion of the large intest ine. Afferent f ibers project to the nucleus t ractus so l i -tar ies (v iscera l , sensory, and taste ) ,

whi le efferent f ibers project f rom the nucleus ambiguous (branchia l ) and dorsa l motor nuc leus . Whi le the sensory a fferent f ibers in the bra instem terminate in the nucleus t ractus so l i tar ies , they send f ibers that connect e i ther d i rect ly or indi -rect ly to d i fferent bra in regions. 7,8 Afferent s ignal ing of the vagus nerve a lso act ivates the hypothal -amus and other CNS nucle i , which regulate the neuro-hormonal HPA ax is . These neurons are associated wi th g lucocort icoid product ion. The s ignals are a lso re layed to the cel l bodies of the efferent para-sympathet ic vagus nerve, which are located the medul lary nuc leus ambiguus. 1

In the heart the baroreceptor ref lex i s act ivated by increases in b lood pressure, which st imulate s t retch receptor in the carot id s inuses and aort ic arc . These receptors t r igger act ion potent ia ls t ransmit ted a long the vagus nerve to the bra instem and other nuc le i , which modulate outgoing blood pressure responses. These inc lude decreased s ignal ing to adrenergic nerves to the heart , reducing contract ib i l i ty and heart rate , whi le mainta in ing blood pres-sure wi th in a narrow homeostat ic range. 1

The vagus nerve f ibers innervat ing the upper and middle gast ro intes-t ina l t ract or ig inate f rom two nucle i in the bra in s tem. The nucleus ambiguous nucleus which reaches the larynx and esophagus, and the dorsa l motor nuc leus of the vagus which reaches the stomach and the descending colon. 9 There is some suggest ion 9 that ‘ the macrophages located between the longi tudinal and c i rcu lar musc led layer at the level of the myenter ic p lexus act as the gatekeepers of the enter ic

37

nervous system. The enter ic ner-vous system forms a dense network of nerve ce l l s near many immune cel l s . Theory suggests the chol iner-g ic tone affects the enter ic nervous system, and vagal innervat ion may modulate the intest ina l env i ron-ment by any immune cel l car ry ing a chol inergic receptor. 9

THE SYMPATHETIC IMMUNE RESPONSE

The sympathet ic nervous system and the immune system are t ight-ly inter twined. There is a large body of research 10 demonstrates the autonomic dysregulat ion can dr ive in f lammat ion by inc i t ing the immune system. I f the s ignal f rom nerve f ibers i s s t rong enough or i f loca l in f lammat ion mediators spi l l into broader c i rcu lat ion such as lymph and blood, the hypothalamus pi tu i tary adrenal (HPA) system and the sympathet ic nervous system act ivates . 10

When an ant igen enters the body, loca l immune cel l s are act ivated, leading to the re lease of pro- in-f lammatory cytok ines and che-mo-messengers such as the tumor necros is factor (TNF) , Inter leuk in 1 ( IL1 ) or Inter leuk in 6 ( IL6 ) . 11 Cy-tok ines are smal l non-ant ibody prote ins secreted by var ious im-mune cel l s inc luding macrophages, T-Cel ls , B-Cel ls , dendr i t ic ce l l s , endothel ia l ce l l s , f ibroblasts and st roma cel l s . Cytok ines are not per-sonal ized by exposure to ant igens l ike ant ibodies . 11

These chemo-messengers regulate immune response. Cr i t ica l condi-t ions inc luding seps is , some cancer, t rauma, rheumatoid ar thr i t i s , and heart d isease 12 are the resul t of an over- response of the immune system. The cytok ines , TNF (a lpha) , I l6 , and I l1 are e levated in a lmost a l l in f lammatory s tates and recog-nized targets for t reatment in many of the new bio logic drugs enter ing the market . 11, 13 The chemo-s ig-nals can e i ther exc i te or lower the thresholds for sensory pain recep-tors and sensory vagal nerve f ibers .

Communicat ion between the bra in and immune system toggles between levels of cytok ines . For example, in a s tudy 14 involv ing hypertens ive medicat ion of meno-pausal women, reduct ion in b lood pressure down-regulated sympa-thet ic act iv i ty, thereby reducing TNF serum levels . In another s tudy-15down-regulat ing the sympathet ic system coinc ided wi th a reduct ion in IL-6 . 10 Other research 10 shows that communicat ion between the

bra in and area of in f lammat ion can be modi f ied by a s t roke; doctors and sc ient is ts 10 have noted other ev idence of in f lammatory reduct ion in the region of para lys is of a pa-t ient wi th an in f lammatory condi-t ion such as rheumatoid ar thr i t i s . In pat ients 10 who have had even a minor s t roke or pol iomyel i t i s , thei r immune response is a l tered on the affected s ide. In rat models , a sym-phathectomy leads to a reduct ion in in fect ion rates . 10,16

I t has been shown that second-ary lymphoid t i ssue, such as the spleen, i s innervated by sympathet-ic nerve f ibers , and nerve termi-nals wi th in the v ic in i ty of immune cel l s . 10 Immune cel l s express re-ceptors for neurotransmit ters . One such group of t ransmit ters on im-mune cel l s has been named adreno-receptors (AR) . There are many sub-c lasses of adrenoceptors on nerve endings and other k inds of t i ssue, inc luding receptors that act ivate the immune system by responding to adrenergenic s t imulat ion. 17 TNF was the f i rs t of many cytok ines that was shown to respond to catechol -amines that belong AR category. 10

Sympathet ic nerve endings re lease not only norepinephr ine, but n i -t rous ox ide, neuropept ide y (NPY) , and adenosine t r iphosphate, ATP. Whi le norepinephr ine may be the best understood neurotransmit ter a ffect ing the immune system, i t has a lso been shown that an NPY antagonist reduces in f lammat ion in rats wi th chemical ly induced rheu-matoid ar thr i t i s . 10 Immune cel l s can be di rect ly a ffected by the sympa-thet ic nervous system through thei r own adrenoceptors , or indi rect ly in f luenced through f low of b lood or lymph, whereby they regulate the product ion and dist r ibut ion of lym-phocytes , or modulate pro- inf lam-matory pept ides such as substance P e l ic i ted f rom sensory nerve endings. 10

The sympathet ic nervous system is involved in changes in leuko-cyte d is t r ibut ion and immune cel l recru i tment throughout the body. A recent t i ssue study 13, showed that Beta AR’s (beta adrenoceptors ) were expressed on non-hematopoi-et ic ce l l s , leading to the express ion of endothel ia l ce l l adhes ion mole-cules and chemokines ; a s igni f icant s tep in accelerat ing an in f lammato-ry response. This pathway can be a s tepping stone toward degener-at ive d isease such as atherosc lero-s is 18,19 or the format ion of second-ary cancers . 13,19 In another s tudy the sympathet ic nervous system effected recru i tment of monocytes

CAN ACUPUNCTURE BIO-HACK THE AUTONOMIC NERVOUS SYSTEM AND DOWN-REGULATE INFLAMMATION? (CONT.)Dr. Sharon Hennessey, DAOM, L .Ac.

f rom the spleen dur ing a per i toneal in fect ion. 10

Nei ther cytok ines , thei r receptors , or neurotransmit ters behave in a s imple d ig i ta l manner. There is a profound dia lect ic of c ross ta lk between them 6; receptors respond-ing on the sur face of immune cel l s to neurotransmit ters , cytok ines affect ing nerve endings which in turn affect the autonomic nervous system and sensory nerves ; out-put and input juggl ing a conver-sat ion between what i s both loca l and centra l . There are no s imple caveats such as norepinephr ine is pro- inf lammatory. Neurotransmit -ters may contradict one another ’s messaging, and to add to the mix , the sympathet ic nervous system is d i rect ing nonimmune cel l s to reduce the in f lammatory process , whi le redef in ing input f rom sensory nervous system. 6,10

THE INFLAMMATORY REFLEX: THE VAGUS NERVE GUIDES THE IMMUNE SYSTEM

In th is compl icated e lectro-chem-ica l conversat ion, the vagus nerve plays a prominent ro le in suppress-ing in f lammatory cytok ine chat-ter. Dr. Tracey has descr ibed th is phenomena as ‘ the in f lammatory ref lex ’ . 1 The vagus nerve terminates in the cel iac gangl ion, never reach-ing the spleen; however, e lect r ica l s t imulat ion of the vagus nerve above the cel iac gangl ion or the splenic nerve s igni f icant ly inh ib i ts TNF product ion in the red pulp and marginal zone macrophages of the spleen. Nerve f ibers in the spleen that or ig inate in the cel iac gan-gl ion are adrenergic , responding to norepinephr ine as the pr imary neurotransmit ter. The vagus nerve s i tuated upstream f rom the sym-pathet ic ce l iac gangl ion, somehow act ivates n icot in ic acetychol ine receptors (nACH7) on macrophages that respond to the neurotransmit -ter acety lchol ine which substant ia l -ly down-regulates TNF. 20

W ith in minutes of Tracey et a l . apply ing e lectr ica l s t imulat ion to the vagus nerve, acetychol ine levels were e levated, reaching a peak twenty minutes later. These sc ient is ts postu lated that perhaps lymphocytes synthes ize and re lease the neurotransmit ter in response to norepinephr ine. They a lso postu-late that these T ce l l s are located not only in the spleen but Peyer ’s patches and lymph nodes, widen-ing the in f luence of vagus nerve s ignal ing. 20, 21

Reduced heart rate var iabi l i ty (HRV)

38

i s a symptom associated wi th a r i se in cytok ine levels . This may be prompted by both Pathogen or Danger Associated Molecular Pat-terns (PAMP or DAMP) . 22,23,1 Many acute and chronic in f lammatory d isease are associated wi th such molecular patterns and accompa-nied by a reduct ion of heart rate var iabi l i ty. These inc lude seps is 24, hemmorhagic shock 25, myocardia l in farct ion 26,27, rheumatoid ar thr i t i s 28, or u lcerat ive col i t i s 29,30, but a lso condit ions l ike metabol ic syndrome or d iabetes 31. Tracey and h is col -leagues have shown that by int ro-ducing endotoxin into a rat per i to-neal cav i ty, there was a reduct ion in heart rate var iabi l i ty. Vagal s ignal -ing was conjo ined to HRV response, and reduced the response of innate immunity. 1, 32

Dendr i t ic ce l l s , re leas ing Inter leu-k in ( IL -1Beta) and prostaglandins , are located wi th in v ic in i ty of vagus nerve f ibers . In ject ion of bacte-r ia l endotoxin or administ rat ion of IL -1Beta, a cytok ine, act ivated afferent vagus neurons. These sc i -ent is ts pos i t that s ignals through the afferent vagus nerve reach the nucleus t ractus so l i tar ies in the bra instem port ion of the medul la . This i s where interconnect ions to the dorsa l motor nuc leus of the vagus nerve efferent vagus nerves f ibers or ig inate. Tracey et a l . have demonstrated that there i s a fferent nerve act iv i ty in the thymus and the splenic nerve as a response to inter leuk in IL-1beta and endotox-in . 31,33

Ninety- four percent of TNF re-leased systemica l ly in ear ly phase toxemia in a rodent model or ig i -nates in the spleen, and has been shown the splenectomy protects against the lethal e ffects of sep-s is . 34 Dr. Tracey and col leagues make a case that the spleen is the pr imary target for s ignals f rom the efferent arm of the vagal neurons. W ith in the cel iac p lexus gangl ia , vagus nerve f ibers t ransmit in-format ion through interneurons or postsynapt ic cate-chol inergic neurons. Whi le the centra l ner-vous system t ransmits s ignals f rom sympathet ic chain , accumulat ing data 1,3,21,33 indicates the vagal ef -ferent s ignal ing is requi red for the in f lammatory ref lex to occur. The in f lammatory ref lex response is nei -ther c lass ica l ly parasympathet ic nor sympathet ic but an amalgamat ion of neura l communicat ion .33,34

Just to rev iew, present ly, research-ers th ink the c i rcu i t ry involv ing va-gus input f in ishes on cytok ine pro-ducing macrophages. F i rs t neuron

is sensory, in format ion goes in the bra in ; second is efferent ( leaves the bra in ) and chol inergic . The chol in-ergic efferent branch of the vagus t ravels near the cel iac sympathet ic gangl ion, which connects to a th i rd adrenegic neuron. This connects to the splenic nerve to del iver nor-epinephr ine to Beta-2 adrenergic receptors expressed on a subset of T-cel l s capable of secret ing acety l -chol ine. T-cel l s are act ing in p lace of chol inergic neurons, act ivat ing the nACH7 receptors expressed on cytok ine producing macrophages. This occurs in marginal zone and red pulp of the spleen. These macrophage nACH7 receptors then suppress cytok ine t ranscr ipt ion and re lease. 35 The efferent vagus nerve indi rect ly modulates the immune response.

This i l lust rat ion descr ibes the in f lammatory ref lex — the pathway for reducing cytok ines by adjust ing the in f lammatory response in the spleen. Acety lchol ine, the major vagal neurotransmit ter, d imin ished the re lease of TNF and inter leuk ins ( IL -1 beta , IL -6 and I l -8 ) . 1

I t i s the vagal efferent s ignal that act ivates macrophages that a lso modi f ies heart rate var iabi l i ty. The chol inergic response to nACH7 receptors s lows the heart rate v ia the muscar ic chol inergic receptors on heart pacemaker ce l l s . 36 Vagus response increases the var iat ions between heartbeats . The lack of heart rate var iabi l i ty can be an in-dicator of autonomic dysregulat ion. Dr. Tracey and other sc ient is ts 37

suggest the heart rate var iabi l i ty may qual i fy as an indicator at who may be at greater r i sk for h igh lev-e ls of in f lammat ion.

STUDIES THAT DEMONSTRATE ACUPUNCTURE DOWN-REGU-LATES INFLAMMATION

In recent s tudy by Zhou et a l . 2 func-t ional dyspepsia and gastr ic emp-ty ing were measured in rat pups before and af ter aur icu lar e lec-t ro-acupuncture. Gastr ic d is tens ion or funct ional dyspepsia was rated by behavior indicat ing discomfort . Autonomic funct ions were assessed f rom the spectra l analys is of heart rate var iabi l i ty der ived f rom an e lectro-cardiogram. Funct ional dys-pepsia d imin ished in rats t reated wi th aur icu lar e lect ro-acupunc-ture but gast r ic empty ing was not a l tered. 2

Other avenues were explored by Zhou et a l . Two di fferent sets of e lect r ica l prescr ipt ions were imple-mented, indicat ing that the f re-quency of e lect r ica l s t imulat ion has a consequence on t reatment effect . These prescr ipt ions were based on the work of Han et a l . 38 that demon-st rated the combinat ion of two f re-quencies , 2 hz and 100 hz produced a l l 4 opio id pept ides , enhancing the effect of e lect r ica l s t imulat ion. Sun et a l . 39 used Han’s prescr ipt ions to reduce v iscera l sens i t iv i ty in rats wi th gast r ic u lcer. This research of Han and Sun was the bas is of Zhou’s choices in choosing f requen-c ies for reducing gastr ic dyspepsia .

Naloxone was in jected int raper-i toneal ly into the rats before e lect ro-acupuncture t reatment to examine the opioid mechanism. 2 Surpr is ingly, the drug, an opioid antagonist , d id not b lock the ef -fects of aur icu lar e lect ro-acupunc-ture on the autonomic funct ion. In a prev ious s tudy 40, Zhou and col leagues determined e lectro-acu-puncture at ST 36 mediated both autonomic and opioid pathways , but a lso operated independent ly f rom the opioid pathway. Naxlox-one did not inh ib i t the t reatment effects in th is s tudy 2; and aur icu-lar e lect ro-acupuncture increased vagus nerve act iv i ty and improved sympathovagal balance.

Zhou et a l . dev ised two sets of e lect r ica l prescr ipt ions . The f i rs t was based di rect ly on the work of Han and Sun. This prov ided inter-mit tent f requency of 2 hz and 100 hz . Bes ides inducing opioid path-ways , Sun had shown th is protocol reduced v iscera l hypersens i t iv i ty. 39 Another set of parameters were

39

CAN ACUPUNCTURE BIO-HACK THE AUTONOMIC NERVOUS SYSTEM AND DOWN-REGULATE INFLAMMATION? Dr. Sharon Hennessey, DAOM, L .Ac.

added that had cons is tent ly shown to reduce gastr ic empty ing. I t con-s is ted of 2 seconds on, 3 seconds

off , a t 25 hertz . 2,40 Interest ingly, re-searchers d iscussed another s tudy 41 in which aur icu lar e lect ro-acu-

puncture was reported to improve recta l d is tent ion induced gastr ic dysrhythmias .

In another recent animal s tudy at Rutgers Univers i ty s tudy by Torres , Rosa, and Ul loa, et a l . 3 demonstrat -ed e lectr ica l ly s t imulat ion of ST 36 (Zu San L i ) a t 10 Hz, in cont inuous mode act ivated the common t ib ia l and peronal branches of the sc iat ic nerve. In th is e lect ro-chemical thread, Zu San L i St 36 by way of the sc iat ic nerve leads to produc-t ion of dopamine in the adrenal medul la . These resul ts suggest the product ion of catecholamines i s moderated by the vagus nerve. Do-pamine inhib i ts cytok ine product ion by dopamine (D1) receptors in the medul la indicat ing another path of vagus nerve inter ference. As dopa-mine product ion can modulate the immune system, animal s tudies sug-gest e lect ro-acupuncture at Zu San L i ST 36 post-surgica l ly decreases in f lammatory cytok ines .3

The effects of e lect ro-acupuncture at Zu San L i T 36, descr ib ing how by act ivat ing the sc iat ic nerve, systemic in f lammat ion was reduced by vagal act ivat ion of a dopamine precursor in the adrenal medul la . 3

VAGUS NERVE THERAPY

Electr ica l dev ices , of ten surgica l ly implanted micro cuffs , are now em-ployed in the t reatment of epi lepsy, depress ion, and rheumatoid ar thr i -t i s . E lect r ica l s t imulat ion of the le f t vagus nerve is an approved therapy for epi lepsy. Some studies 7 sug-gest that low ampl i tude (<1.5mA) and h igh f requency (20 hertz ) s t im-ulat ion is e ffect ive for depress ion. The device most commonly em-ployed is a battery powered pulse generator that requi res a surgica l implantat ion. The generator i s in-serted subcutaneous ly in le f t upper chest wal l , whi le an e lectrode wi re i s at tached to the le f t mid-cerv i -ca l vagus nerve through a second inc is ion in the upper le f t region of the neck. A handheld comput-er programs the pulse generator. Unfortunate ly, s t imulat ion of the mid-cerv ica l vagus nerve may affect the voice, breath ing, swal lowing and the neck. I t a lso generates uncomfortable sensat ions of pares-thes ia in the upper body. E lect r ica l impulses generated at area have a greater effect on the bra in s ince the bulk of nerve f ibers are affer-ent . 7

Recent ly, an Is rael i company de-veloped a cuff des igned to c i rcum-nav igate the vagus nerve. This new des ign favored act ivat ion of vagal efferent f ibers that a ffect cardiac funct ion in the r ight chest wal l . So far, s tudies 7 (prec l in ica l , and phase I I ) indicate th is dev ice i s safe . The same cuff was re-engineered for the le f t s ide of vagus. F ive pat ients were t reated for epi lepsy wi th the newly des igned cuff and s ide effects in the upper region of the body dimin ished .7 There is some anatomical ev idence that the r ight cerv ica l vagus nerve st imulat ion has a greater effect on the heart , but t reatment for heart fa i lure us ing such devices has not be part icu lar ly successfu l . The cerv ica l neck area conta ins abundant sympathet ic f ibers , part icu lar ly the r ight vagus nerve, indicat ing both sympathet ic and vagus nerves t ravel in a com-mon t runk. Others pos i t that t rans-cutaneous st imulat ion of the vagus nerve in the ear might be a better avenue for t reatment , preferent ia l ly

engaging only the vagus nerve. 44 The aur icu lotemporal , greater aur icu lar and aur icu lar branch of the vagus nerve innervate the ear. The cymba conchae of the ear i s innervated exc lus ive ly by aur icu lar branch of the vagus nerve. Pat ients can se l f -adminis ter t reatment d i -rect ly to the cymba concha. Such a dev ice has a l ready received Euro-pean government c learance for the t reatment of epi lepsy and depres-s ion. A TENS ( t ranscutaneous e lec-t r ica l nerve st imulator ) can a lso be used to s t imulate the cymba concha e i ther uni latera l or b i latera l . 44

Another dev ice inc ludes contact pads that are p laced over both branches of the vagus nerve in the region of the upper neck. The in-tens i ty of the st imulat ion is d i rect -ed by the pat ient wi th a handheld device. This des ign is intended to re l ieve c luster and migra ine head-aches. The USDA (FDA) recent-ly approved a s imi lar hand-held device ca l led, gammaCore, for the t reatment of c luster headaches in adul ts . In a smal l s tudy 45 pat ients were pain- f ree in 15 minutes .

SetPoint Medica l Devices devel -oped by Dr. Tracey and h is col -leagues in i t ia l ly modi f ied a s t imu-lator des igned for the t reatment of epi lepsy. They have demonstrated the macrophages h i t by acety lcho-l ine are unable to produce TNF for up to twenty- four hours . Addi-t ional ly, vagus nerve f ibers requi re very low e lectr ica l s t imulat ion, approximately one e ight typica l ly requi red for epi lepsy to respond to a t reatment . In 2011, SetPoint Devices 5 were tested on human subjects in Amsterdam and at the UK-based pharmaceut ica l company GlaxoSmithKl ine. Over the course of severa l years e ighteen people wi th rheumatoid ar thr i t i s enrol led in the study. Twelve part ic ipants s tated thei r symptoms improved over s ix weeks . Lab tests demon-st rated the blood levels of in f lam-matory molecules , such as TNF and IL-6 , decreased. Improvements vanished when the devices were shut off for two weeks , but returned when st imulat ion was restar ted. 5 Dr. Bruno Bonaz 46, a gast roenterologist

40

f rom Grenoble, was t reat ing seven people wi th Crohn’s d isease. F ive people reported fewer symptoms, and endoscopies showed reduced t issue damage. The study was never publ ished. SetPoint i s a lso en-gaged in a c l in ica l t r ia l for Crohn’s d isease. 5

W i l l e lect ro-ceut ica ls be the next t reatment breakthrough? E lectr ica l s t imulat ion of the vagus nerve is an accepted t reatment , and medica l dev ices are being marketed in Eu-rope, I s rael , and the Uni ted States . Glaxo Smith K l ine is partner ing wi th Google. US Nat ional Inst i tute of Heal th (NIH) has announced a program cal led ‘St imulat ing Per iph-era l Act iv i ty to Rel ieve Condit ions ’ ; the object — to update neura l maps in the abdominal and tho-rac ic cav i t ies . 5 Medica l researchers a l ready cons ider t reatment of the vagus nerve at the ear or neck wi th e lect r ica l s t imulat ion as a l ike ly therapeut ic intervent ion for i r r i ta-b le bowel d isease or rheumatoid ar thr i t i s . 9,46 These new devices du-pl icate aspects of the acupuncture exper ience, but many acupunctur-i s ts are in the dark about the why thei r technique is e ffect ive.

CONCLUSION Th is research, understanding how the immune system and autonom-ic nervous system are co- jo ined, should be part of an acupuncture vocabulary. As acupunctur is ts , we know that ser ies of acupuncture t reatments are an effect ive tool for improving many condit ions , but i t i s important to be able to descr ibe an under ly ing mechanism.

More research may be needed to demonstrate the benef i t of acu-puncture on the autonomic nervous system in s t imulat ing down-regula-t ion. There is ev idence that e lect r i -ca l s t imulat ion to the vagus nerve has a pos i t ive effect on epi lepsy, depress ion, and headache. The ev idence for effect ing the vagus nerve in ser ious condit ions such as seps is , heart d isease, d iabetes , cancers , co l i t i s , and rheumatoid ar thr i t i s , has been demonstrated most ly in an imal s tudies , but there are now a few smal l breakout s tud-ies involv ing human pat ients being t reated wi th e lect r ica l dev ices . Theory now indicates that e lect r ica l s t imulat ion of the vagus nerve may exert a pos i t ive down-regulat ing in f luence on body wide in f lamma-t ion. Furthermore, an imal s tudies indicate e lect r ica l acupuncture at certa in points on the ear and ST 36 dupl icate these effects .

Not only i s i t important for acu-punctur is ts to understand the effect of acupuncture on the autonomic nervous system and the immune system, but they should a lso be able to communicate th is effect to both thei r pat ients and other pro-fess ionals . Whi le more research is being done and more ev idence wi l l

accumulate in the future, research sc ience has generous ly prov ided us wi th a convinc ing umbrel la to s tand beneath. We must master and de-f ine our p lace in th is new paradigm of t reatment .

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39) Sun Y, Tan Y, Song G, Chen JD. (2014) Effects and mechanisms of gast r ic e lect r ica l s t imulat ion on v iscera l pa in in a rodent model of gast r ic hypera lges ia secondary to chemical ly mucosal u lcerat ion. Neurogastroenterol Mot i l 26 : 176–186. ht tps : //doi .org/10.1111/nmo.12248 PMID: 24165025

40) Zhang Z, Y in J , Chen JD. (2015) Amel iorat ing effects of aur icu-lar e lect roacupuncture on recta l d is tent ion- induced gastr ic dys-rhythmias in rats .PLoS One 10: e0114226. pmid:25643282

41) Zhou YY, Wanner NJ, X iao Y, Shi XZ, J iang XH, Gu JG, Xu GY. E lec-t roacupuncture a l lev iates s t ress- in-duced v iscera l hypersens i t iv i ty through an opioid system in rats . Wor ld J Gastroenterol 2012; 18 (48) : 7201-7211

42) Yim Y-K, Lee H, Hong K-E, et a l . E lect ro-acupuncture at acupoint ST36 reduces in f lammat ion and regulates immune act iv i ty in Col la-gen- Induced Arthr i t ic Mice. Ev i -dence-based Complementary and Al ternat ive Medic ine. 2007;4 (1 ) :51-57. doi :10 .1093/ecam/nel054.

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CAN ACUPUNCTURE BIO-HACK THE AUTONOMIC NERVOUS SYSTEM AND DOWN-REGULATE INFLAMMATION? (CONT.)Dr. Sharon Hennessey, DAOM, L .Ac.

mechanism. Neura l Regenerat ion Research. 2015;10(4 ) :576-582. doi :10 .4103/1673-5374.155430.

44) Aaron R. Murray ; The st range case of the ear and the heart : The aur icu lar vagus nerve and i ts in f lu-ence on cardiac contro l ; Autonomic Neurosc ience: Bas ic and Cl in ica l 199 (2016) 48–53

45) FDA Approves Vagus Nerve St imulat ion Device for Cluster Headache; Deborah Brauser, Apr i l 18 , 2017, Medscape, Thursday, Sep-tember 7 , 2017

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