Stimulated by Lu et al 2024.[1]
MMT – methadone maintenance treatment
IF – impact factor
OUD – opioid use disorder
VAS – visual analogue scale
QoL – quality of life
NMA – network meta-analysis
POAS – protracted opioid abstinence syndrome– key to acronyms
This is the second sham controlled trial of acupuncture published in Annals of Internal Medicine (IF 39.2) this month (July 2024).
This time the subject is methadone dose reduction within MMT – not very interesting to the average WMA practitioner, but a very important topic in public health terms.
The study was based in Guangzhou – the huge sprawling port city on the Pearl River northwest of Hong Kong and part of the largest urban conurbation on the planet, with an estimated population of 70 million. I have previously described it on this blog as being north of Macao, which it is, since Macao lies directly west of Hong Kong. It is about an hour by ferry between the two ports, and the ferry sails every hour according to Google.
This trial was based in 6 MMT centres, which all appear to be in Guangzhou based on the affiliations of the 25 authors. On checking the author list, I noticed Madison (Yuqing Zhang) was listed. She is the only one not to have an affiliation based in Guangzhou. To remind readers, she was behind the BMJ series of papers published online in 2022, and frequently highlighted on this blog.
118 patients on MMT for at least 6 weeks and meeting the criteria for OUD were randomised to either real acupuncture or a non-penetrating sham in the same locations. Treatment was performed 3 times a week for 8 weeks followed by 12 weeks of follow-up.
The paper mentions three Chinese names when it comes to describe the points used: Dingshenzhen; Sishenzhen; and Shouzhizhen. They all represent a set of points – 3 points on the forehead, 4 points on the top of the scalp around GV20, and 3 points on the wrist and hand respectively. I have mentioned Sishenzhen previously on the blog: Acupuncture for perimenopausal GAD 2023. This was also the blog where I first came across a sham device that allowed both perpendicular and oblique needle insertion. This device appears to have gone through further refinement beyond when I mentioned it for the second time on the blog: Acupuncture for sleep in PD 2024. Now that I come to review the papers and images, they may not all be the same device, although the research groups do come from the same university.
Dingshenzhen is a set of 3 points on the forehead. Each one is 0.5 cun superior to GB14 and Yintang. Finally, Shouzhizhen is a set of 3 points on the wrist and hand: HT7, PC6, and PC8. The latter three were needled on one arm only, and the side was alternated at each session.
There were 2 primary outcomes stated, which is unusual. The first was the proportion of patients who achieved 20% or more reduction in methadone dose. The second was the change from baseline in opioid craving measured on a 100mm VAS. The baseline mean methadone dosage was just over 40mg and the mean opioid craving was just over 80.
At the 8-week point, 62% of the acupuncture group had achieved a 20% or greater reduction on methadone dose, and a mean reduction in opioid craving of 16.2. By comparison, 29% of the sham group had achieved the same level of reduction, and a mean reduction in opioid craving of 4.5. The difference in both of these measures was very highly significant in statistical terms.
These results are consistent with previous trials by the same group,[2,3] although cost effectiveness was measured to be above the threshold of willingness to pay.[3] The latter may well have something to do with measurement of QoL in this group rather than being an indication of the size of the acupuncture effect.
This group have also published an NMA suggesting manual acupuncture is likely to be the best acupuncture approach in MMT,[4] and they have also performed an SR of acupuncture in POAS,[5] which suggested acupuncture was safe and alleviated protracted withdrawal symptoms to some degree.
So, on the whole this is relatively good evidence for the use of acupuncture during MMT to help reduce dose of methadone and symptoms of opioid withdrawal.
References
1 Lu L, Chen C, Chen Y, et al. Effect of Acupuncture for Methadone Reduction: A Randomized Clinical Trial. Ann Intern Med. Published Online First: 9 July 2024. doi: 10.7326/M23-2721
2 Dong Y, Fan B, Yan E, et al. Decision tree model based prediction of the efficacy of acupuncture in methadone maintenance treatment. Front Neurol. 2022;13:956255. doi: 10.3389/fneur.2022.956255
3 Wen H, Wei X, Ge S, et al. Clinical and Economic Evaluation of Acupuncture for Opioid-Dependent Patients Receiving Methadone Maintenance Treatment: The Integrative Clinical Trial and Evidence-Based Data. Front Public Health. 2021;9:689753. doi: 10.3389/fpubh.2021.689753
4 Wen H, Chen R, Zhang P, et al. Acupuncture for Opioid Dependence Patients Receiving Methadone Maintenance Treatment: A Network Meta-Analysis. Front Psychiatry. 2021;12:767613. doi: 10.3389/fpsyt.2021.767613
5 Ding L, Li C, Zhang P, et al. Acupuncture-related therapies for protracted opioid abstinence syndrome:A systematic review and meta-analysis. Integr Med Res. 2023;12:100976. doi: 10.1016/j.imr.2023.100976
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