In the conduct of this study, the Virginia Board of Medicine has focused on the use of auricular acupuncture in theory and in practice in order to determine the feasibility of this modality for the treatment of substance abuse in the Commonwealth. To understand the issues involved, the study examined the research, consulted with medical, acupuncture, and substance abuse experts, looked at programs utilizing auricular acupuncture, and reviewed regulations in other states and in Virginia.

The first task of this study was to develop an understanding of the modality - how, where, and by whom is it being used. Through the past decade, a protocol for its use has evolved, which now entails the use of 3 to 5 acupuncture needles inserted 1/8" bilaterally in the outer ears without electrical stimulation. [It should be noted that any reference to acupuncture in this report should be so defined as auricular acupuncture.] Used as a tool in the detoxification process, acupuncture is generally delivered by a variety of personnel in the context of a total treatment program. The auricular acupuncture protocol has been taught to substance abuse counselors, nurses, midwives, and others who are involved in the treatment of complex problems associated with addiction. Programs can be found in outpatient alcohol and drug abuse clinics, inpatient facilities, hospitals, jails and prisons, and even in private industry. Retention in acupuncture treatment seems to be a key element in the success of this and any other modality.

A central issue for this study was the efficacy of acupuncture in treating addiction. While anecdotal studies and reports of the therapeutic value of acupuncture are readily available, scientific research on its use has been inconclusive. Agencies such as the National Institute on Drug Abuse have begun an investigation, but studies reviewed were found to be somewhat flawed in their conception or procedure or offered mixed findings and results. The first chapter of this report, therefore, summarized the current literature and presented the views of the medical profession and the agencies involved in alcohol and drug problems. The key finding of this study was that: Scientific evidence of the efficacy of acupuncture as a treatment modality remains inconclusive.

The need for definitive, well-controlled studies on efficacy and long-effectiveness remains. However, considering the current interest in acupuncture, as a treatment modality, from acupuncturists, substance abuse specialists, and those faced with the burden of addiction in the criminal justice system, the Board has recommended that: The Governor's Council on Alcohol and Drug Abuse Problems or some specifically created task force to include representatives of the Department of Health Professionals, MHMRSAS, corrections, and others, should review the findings and recommendations of this study and continue to monitor the research and collection of data on the utilization of auricular acupuncture in substance abuse treatment programs.

To understand the nature and inception of the modality, a great deal of information on acupuncture programs across the country was gathered and reviewed. The Lincoln Hospital clinic in New York has become the model and catalyst for the establishment of more than one hundred programs, the most important of which include the court diversion program in Dade County, Florida, the outpatient clinics in Hennepin County, Minneapolis, and the clinics in Multnomah County, Portland. Self-reported results from these programs include improvement statistics in client retention, in the collection of negative urines, in the reduction in recidivism, in the ability of addicts to assume responsibility, and in the reduced number of boarder babies in hospitals. From evidence gathered and testimony heard, the study found that: Clinical reports from acupuncture-based treatment programs and anecdotal reports from addicted individuals offer subjective evidence of the benefit of auricular acupuncture as a treatment intervention.

Throughout this study, it has been emphasized that acupuncture is not a cure for addiction nor is it effective as a stand-alone treatment. The most ardent proponents describe it as an adjunct that assists in detoxification or empowers the individual to enter treatment in a comprehensive psycho-social rehabilitation program. Therefore, this study found that: No evidence has been presented to indicate the effective use of auricular acupuncture as a treatment modality without the support and involvement of a total treatment program. To be useful in detoxification and early withdrawal from drugs, auricular acupuncture must be combined with a broad-based program of counseling and other interventions in order to be considered effective.

In view of the necessity for coordinated, comprehensive detoxification and treatment services demonstrated by studies and research and by the experiences of acupuncture programs, this study recommended that: Should auricular acupuncture be utilized as a treatment modality for substance or alcohol abuse, it should only be done within the context of an established, comprehensive treatment program.

The study found limited knowledge and acceptability of this concept of acupuncture treatment within the Commonwealth. A small number of physicians and addictionists comprise the group most interested in the modality; while state agencies involved in the conception and administration of policies and programs remain largely uninitiated. Some who have provided information and research for this study have suggested that a demonstration project embodied within an existing treatment program might be useful in offering some data and comparisons with other modalities. While the Board does not endorse such a project, it does recommend that: Should a demonstration project be considered for implementation, it should be done by the Virginia Department of Mental Health, Mental Retardation, and Substance Abuse Services (DMHMRSAS) in cooperation with selected organizations such as Community Services Boards or with the Department of Corrections. An assessment of costs and benefits could assist localities or departments in determining the advisability of the inclusion of auricular acupuncture in substance abuse clinics or in the creation of acupuncture-based court diversion programs. If a demonstration project should be undertaken, there would be some initial funding required. If it should prove to be effective, there would be little or no budgetary considerations after the initial phase since the addition of auricular acupuncture as an adjunct to treatment could be incorporated into existing programs within current funding mechanisms and could theoretically result in a cost-savings due to a reduction in recidivism.

Collection of data on programs and regulations has shown that a wide range exists in the staffing and in the delivery of acupuncture treatment. In order to understand the nature of the acupuncture service, the study included information on the training protocol for auricular acupuncture service personnel, a look at how other states have handled the procedure, and a review of the regulations and laws in Virginia. At present, there is no language to specifically include or exclude the use of auricular acupuncture as a treatment modality. The study found that: The utilization of auricular acupuncture as a treatment modality for substance abuse is feasible under present Virginia law. Currently, there are physician acupuncturists in the Commonwealth utilizing the modality in their practices.

Clearly, the use of ancillary personnel trained as auricular acupuncture technicians for substance abuse treatment would be advantageous if it is to be used extensively or to be most cost-effective. Therefore, the study found that: Data provided by treatment programs and testimony given at the public hearing have demonstrated that a wide range of health and substance abuse personnel can be trained to perform the procedure of auricular acupuncture for the specific purpose of detoxification or addiction control. We believe that such a procedure could be considered to be of a non-discretionary and non-judgmental nature and therefore permissible to trained personnel under the direct supervision of physician acupuncturists under current Virginia Law. (Section 54.1-2901)

In Section 54.1-2901, the Code of Virginia provides certain exceptions and exemptions from the General Provisions on the "Practice of medicine." The provisions of the chapter do not prohibit a "physician from delegating to personnel in his personal employ and supervised by him, such activities or functions as are nondiscretionary and do not require the exercise of professional judgment for their performance and which are usually or customarily delegated to such persons by physicians, if such activities or functions are authorized by and performed for such physicians and responsibility for such activities or functions is assumed by such physicians."

Further, the study found that: "If the delivery of auricular acupuncture in substance abuse programs performed by trained technicians under direct supervision of licensed physician acupuncturists according to statutory provisions in the Code for nondiscretionary, non-judgmental activities is debatable, then the legislature would need to consider an exemption for auricular acupuncture used exclusively and specifically for substance abuse in the statutory exclusions listed in the definition of the "Practice of acupuncture" found in Section 54.1-2900. Should a decision be made to institute such a program for addiction, the legislature would want to consider the addition of auricular acupuncture used exclusively and specifically for substance abuse treatment in the listing of activities excluded in the practice of acupuncture.

While the direct supervision of a physician acupuncturist over the administration of auricular acupuncture would provide reasonable safety to the public, concerns about training and sterilization procedures have led to two additional recommendations: That any personnel trained to perform auricular acupuncture under the supervision of physician acupuncturists receive their training in a program with a protocol approved by the Board of Medicine similar to that approved by the National Acupuncture Detoxification Association, Inc. and That auricular acupuncture treatment for alcohol or substance abuse should be performed only with the utilization of disposable needles.

In summary, the Board was requested to examine the feasibility of acupuncture as a modality of treatment. It has found its effectiveness lauded by anecdotal reports but unsubstantiated by scientific study and governmental policy. In no case was the modality found to be useful apart from its inclusion in a comprehensive treatment program. It has found that the use of auricular acupuncture for detoxification is feasible under Virginia law.

Since the question of efficacy remains, the Board has recommended that continued review of the data and research be undertaken by some agency of the Commonwealth. The Board has not recommended its use or the initiation of any program. It does, however, recommend that any utilization of auricular acupuncture should be done within the context of a total treatment program by personnel trained in a specific protocol and employing only disposable needles. The Board further recommends that if a demonstration project is undertaken, it should be initiated and monitored by the appropriate agency of the Commonwealth.