Trendy Drugs of Abuse

shutterstock_10131886Healthcare professionals across the country are seeing a new and alarming trend in drug abuse.  As doctors and parents, it is important that we are aware of these substances and understand how patients who use them may present.

1)   Dextromethorphan (“Robotripping”):  Street names are DXM, CCC, High C and skittles.  These are most commonly seen in boys between 10-14 years of age.  Dextromethorphan is commonly found in cough syrups such as Robitussin and is ingested at about 25 times the therapeutic dose. It causes a dissociative anesthesia similar to PCP.  They are often other ingredients in these common cold medications such as Tylenol and chlorpheniramine that can cause harmful effects on the body including permanent liver damage.  The effects of the dextromethorphan can include decreased alertness and transient hallucinations and risk for trauma due to the dissociative effects.

2)   Bath Salts (MDPV):  These are not actual bath salts, but designer hallucinogenic amphetamines or a newer version of “ecstasy” (MDMA).  Common names on the market now include “M-shine” and “hooka cleaner.”   The core substance is cathinone (from the khat plant).  Patients often present with increased reflexes, teeth grinding (bruxism) and involuntary muscle contractions (clonus).  They can have an increased heart rate and may have seizures and can exhibit psychotic behavior or paranoia (that may last for days).  Other worrisome problems associated with bath salt use include running a very high fever, forming abnormal blood clots in the legs or lungs, and liver failure.

3)   Jimson weed (Thorn Apple):  Commonly found growing in back yards, each plant contains seed pods with numerous seeds. Each seed contains a varying amount of the drugs atropine, scopolamine and hyoscyamine.  Eating seeds from one plant may produce a “mild trip” while ingesting seeds from another plant may contain 10-50x the amount of these drugs and produce skin redness, dilated pupils, delirium, urinary retention, decreased gastrointestinal motility and rapid heart rate.

4)   Psilocybin mushrooms:  The spores of the parent plant are harvested and are often distributed by gluing the spores to paper and then sold as “art.” When ingested, the seed spores may cause hallucinogenic effects.  These are typically sold with a 10-mm syringe and a broth solution.

5)   New marijuana drugs (THC homologues):  Street names include “spice” and “K2”.  Often sold in combination with herbs for smoking.  These are unregulated herbal substances which are often mixed with alcohol or acetone and sprayed on a plant which is then dried and sold.  A single joint contains much higher doses of THC (300mg) than traditional THC.  Clinical effects may include red eyes, rapid heart rate, dry mouth, and perceptual changes.  Agitation, hallucinations and displaying behavior that may lead to trauma.  Synthetic marijuana can also cause seizures, or acute psychotic episodes that can lead to suicidal thoughts.  Other problems such as chest pain, psychological dissociation and panic attacks may occur.  Sometimes the synthetic marijuana that has been sprayed on plants is also combined with formaldehyde (solvent containing PCP) that causes the user to present as acutely psychotic and violent.  Most urine drug screens unfortunately do not detect these substances.

6)   “Pharming, bowling or fruit parties”:  This is a practice where teenagers get together and bring samples of medication that they get from their home (most commonly from their parents’ medicine cabinet).  All samples are placed in a bowl and pills are ingested randomly.  Overdoses on medications for diabetes, high blood pressure and heart problems are common in addition to possible respiratory depression and even death from narcotics, or benzodiazepines or the mixture of multiple substances.

7)   Soma Coma:  Also called “Trinity” if mixed with other drugs.  Soma (carisoprodol) is a non-scheduled drug that is marketed as a muscle relaxer.  It is very similar to a benzodiazepine such as Valium and heavily abused.  It is a heroin substitute when combined with other drugs and its effects are very unpredictable and may predispose the individual to injuries from falls or other trauma.  Many of these users have a history of heroin abuse.

8)   Salvia divinorum:  This is a mint plant common in Mexico.  It is dried and concentrated before being sold, often in online tobacco shops. The salvinorin A contained in the plant is a psychoactive chemical.  It is usually ingested by smoking in a water bong.  Produces a trance-like high for 5-10 minutes.

9)   Alprazolam:  Abuse is on the rise as this medication is commonly used as a “downer” after cocaine use.  Because of its characteristic shape, street names including “candy bars,” “coffins,” or “french fries” may be used.  Pills are swallowed, crushed and snorted.

10)  Cocaine:  Because of the expense, not much cocaine sold on the street is pure. In fact up to 30-40% of some samples contain a common medication used to treat worms in veterinary animals. Highest use among those 18-25 years of age.  Patients who use cocaine may present to a hospital or clinic having a high fever and have low blood cells or platelets, and have red spots on their nose or ears. Cocaine also increases the stickiness of platelets and therefore increases risk of heart attack or stroke. Look for blisters on the thumb and index finger of the dominant hand and scabs or burns around the lips.

11)  Methamphetamines:  After marijuana, it is the most widely abused drug worldwide.  Approximately 5% of the US population has used methamphetamine, with an estimated 500,000 people using the drug in a given month.  It may be synthesized via simple reactions using readily available chemicals and over-the-counter cold medicines, such as Sudafed.   May be ingested orally, rectally, vaginally, be injected, inhaled, or sniffed.  The effects are stronger and last longer than cocaine.  In fact, the prolonged duration of action of methamphetamine (approximately 20 hours) helps differentiate it from cocaine (duration of action 30 minutes) and PCP (duration of action less than 8 hours).  It causes rapid physical deterioration, weight loss, and poor dentition (“meth mouth”).  Life-threatening intoxication is characterized by high blood pressure with rapid heart rate and severely agitated delirium, fever, metabolic acidosis and seizures.  Medical providers should consider diagnosis of methamphetamine intoxication in any sweaty patient with high blood pressure, rapid heart rate, severe agitation and psychosis.  Acutely intoxicated patients may become extremely agitated and pose a danger to themselves, other patients, and medical staff.  Symptoms of methamphetamine withdrawal may develop within hours and typically peak within 1-2 days, and most often decrease within 2 weeks.  During the acute withdrawal period (“the crash”), signs and symptoms may include restlessness, the inability to experience pleasure, fatigue, increased sleep, vivid dreams, insomnia, agitation, anxiety, drug craving and increased appetite.  The prolonged withdrawal phase can last for up to 3 weeks and can include insomnia or even increased sleep, appetite changes, depression and possible suicidal thoughts.

12)  Inhalants (poppers, snappers, rush):  The use of these substances usually decreases as the individual grows older.  Can cause a rapid high, drowsiness, lightheadedness, agitation as well as belligerence, impaired judgment, balance problems, and addiction.   These inhalants may include halogenated hydrocarbons (butane), VCR head cleaner, whipped cream (contains nitrous oxide), colored spray paint (gold color is most popular), amyl and butyl nitrates (poppers, snappers, rush).  “Sudden sniffing death syndrome” is a worrisome problem.

13)  Opiates:  These are also commonly called narcotics (heroin, Demerol, morphine, codeine, fentanyl, oxycodone, hydrocodone, and methadone).  Patients who overdose are often sleepy and have a decreased respiratory rate, decreased gastrointestinal motility, urinary retention and pinpoint pupils.  As a medical provider it’s important to strip an overdosed patient and look for fentanyl patches on the body, but be careful of possible uncapped needles or syringes in the pockets.

There are an increasing number of patients being diagnosed with hepatitis C linked to heroin and other opioid use and that rate is expected to continue increasing.

Street Price:  Vicodin (hydrocodone/Tylenol) is a prescription medication with a street value of $5/pill depending on the geographic location where it’s purchased.  Percocet (oxycodone/Tylenol) or OxyContin sells for about 50 cents to $1/mg but again this varies depending on geographic location and how much is purchased. Buprenorphine/naloxone (Suboxone) which is often prescribed to patients who have a narcotic addiction sells for $5-$20/pill on the street.

Patients presenting to the medical clinic may present in the state of overdose, drug-seeking or withdrawal.  Treatment of overdose may include the use of naloxone.  Narcotic withdrawal symptoms may occur on the first or second day of being without the drug.  Patients may present with goose bumps (where the saying “quitting cold turkey” came from), patients on the third day may be on the floor flapping about with muscle cramps or kicks (i.e. “kicking the habit”).  Other symptoms include anxiety, insomnia, yawning, tearing, sweating, runny nose, all over muscle aches, nausea, vomiting, diarrhea, hot and cold flushes, muscle twitches, abdominal cramps.  Onset of symptoms usually occur within 8 hours of last use with a peak in 2-3 days.  Treatment of withdrawal symptoms may include clonidine, ibuprofen, Benadryl, Phenergan, or Imodium.

It is important for medical providers, parents, law enforcement and teachers to be educated about drugs of abuse that our patients are using and be able to recognize the symptoms of intoxication, drug-seeking or withdrawal and treat our patients appropriately.  The first step in helping protect our patients is learning about some of the drugs of abuse, and signs and symptoms of abuse.

This document is for informational purposes only, and should not be considered medical advice for any individual patient.  If you have questions please contact your medical provider.

 

I hope that you have found this information useful.  Wishing you the best of health,

Scott Rennie, DO

Blog: https://doctorrennie.wordpress.com

 

References:

Clinical experience with and analytical confirmation of “bath salts” and “legal highs” (synthetic cathinones) in the United States, Clin Toxicol (Phila), 2011 Jul; 49(6):499-505

Severe toxicity following synthetic cannabinoid ingestion. Clin Toxicol (Phila), 2011 Oct;49(8):760-4

White, Suzanne R  (2011, November) Current Trends in Drug Abuse, Lecture Detroit Trauma Symposium, Detroit, MI.

Kloss, Brian T (2011, June) Drugs of Abuse Seen in the ED, Lecture – Impact 2011 AAPA Annual Conference

It’s “Voggy” out there… What are the long term effects of vog (volcanic pollution)?

shutterstock_153524036Vog is a form of air pollution that results when sulfur dioxide and other gases and particles emitted by an erupting volcano react with oxygen and moisture in the presence of sunlight. The word is a portmanteau of the words “volcanic” and “smog“. The term is in common use in the Hawaiian islands, where the Kīlauea volcano, on Hawaiʻi Island (aka “The Big Island”), has been erupting continuously since 1983. Based on June 2008 measurements, Kīlauea emits 2,000 – 4,000 tons of sulfur dioxide every day.

Vog poses a health hazard by aggravating preexisting respiratory ailments, and acid rain damages crops and can leach lead into household water supplies. The U.S. Geological Survey’s Hawaiian Volcano Observatory is closely monitoring gas emissions from Kilauea and working with health professionals and local officials to better understand volcanic air pollution and to enhance public awareness of this hazard.

Like smog, the presence of vog reduces visibility. Moisture in the air causes vog particles to enlarge, decreasing visibility still further. On the Island of Hawai`i, people often turn their headlights on during daylight hours when driving in vog, and vog sometimes limits visibility for air traffic.

By Roger Mari –

KEWALO BASIN (KHNL) – Months of heavy vog might have some wondering what the long term affects the sulfur oxide in the air has on our health.

A respiratory expert shared information on a study of volcanic pollution.   The results might come as a surprise to many.

Leading the ongoing research is Doctor Elizabeth Tam.  She believes volcanic pollution or vog can trigger an asthma attack in people including children already diagnosed with the condition.

“We don’t think volcanic air polution actually causes asthma,” said Dr. Tam.

The March eruption of Kilauea’s Halemaumau crater sent large amounts of sulfur dioxide into the air making for more voggy days this year.   Not ideal for photographs, jogging and other outdoor activities, but the vog provides the perfect lab for research.

“There have been times we’ve been in the schools studying, doing our thing and the air polution is much more than before,” Tam said.

The group of children were first examined before they were teens.   Voggy days had the usual effects on them as they would on those who were otherwise healthy.

“We get more of the upper respiratory effects nose, eyes, stinging throat etc., but it doesn’t appear to be asthma,” said Tam.

Researchers including Doctor Tam, will continue the study on the select group of children which began six years ago.

“We’re actually studying the long term effects of the kids, so we continue to study the children which is good,” she said.

So far vog does not appear to be the cause of asthma in the select group of big island children.

But one thing is certain, island residents could be living with vog for years to come.

The idea is to study the children as they grow up.   They were as young as 12 to 14 when research began.

The plan is to monitor their respiratory conditions until they are 18.

2012 Immunization Recommendations

shutterstock_153048518I often get asked questions about immunizations, such as when they are supposed to be given and what they are for.  Here is a list of the 2012 recommended immunizations, when they are supposed to be given and what they are for.  At the end of the list, I will explain abbreviations stand for and a little about the diseases that they protect against.

Birth (child gets this before leaving the hospital):  HepB

2 months:  HepB, DTaP, PCV, Hib, Polio, RV

4 months:  DTaP, PCV, Hib, Polio, RV

6 months:  HepB, DTaP, PCV, Hib, Varicella, HepA, influenza (yearly)

12 months:  MMR, PCV, Hib, Varicella, HepA

15 months:  DtaP,

4 years:  DTaP, IPV, MMR, Varicella, influenza (yearly)

7-10 years:  Tdap, influenza (yearly)

11-12 years:  MCV4, HPV – women (3 doses), influenza (yearly)

16 years:  MCV4, influenza (yearly)

19-21 years:  HPV vaccine, MMR, influenza (yearly)

22-65+:  Tdap vaccine once, then a booster every 10 years, influenza (yearly)

27-59:  Varicella(chicken pox) unless you’ve had the disease, influenza (yearly)

60-65+:  Shingles vaccine, influenza (yearly)

65+:  Pneumococcal vaccine, influenza (yearly)

Abbreviations explained:

HepB:  Protects against hepatitis B (a virus that attacks the liver and can lead to cancer)

DTaP:  a combined vaccine that protects against diphtheria, tetanus, and pertussis (whooping cough).  Diphtheria can cause swelling of the heart muscle, heart failure, coma, paralysis and death.  Tetanus can cause difficulty swallowing, muscle spasms, difficulty breathing and death.  Whooping cough can cause a severe pneumonia (lung infection) and death.

Hib:  Protects against Haemophilus influenza type b.  With this infection there may be no symptoms unless bacteria enter the blood.  An infection with Haemophilus influenza type b can cause meningitis (infection of the covering of the brain and spinal cord), mental retardation, epiglottis (life threatening infection that can block the windpipe and lead to serious breathing problems) and pneumonia (infection in the lungs) and death.

PCV:  Protects against pneumococcal disease which may cause pneumonia, as well as a serious blood infection and meningitis (infection of the covering around the brain and spinal cord) and death.

Polio (IPV):  Protects against polio.  Polio may cause no symptoms until a serious infection develops and then it cause paralysis and death.

RV:  Protects against infections caused by rotavirus.  Rotavirus causes severe diarrhea, vomiting and fever and may lead to dehydration.  It has caused death from dehydration in young children.

Influenza:  Protects against influenza (flu)

MMR:  Protects against measles, mumps, and rubella (German measles).  Measles can cause a rash, fever, encephalitis (brain swelling), pneumonia (infection in the lungs) and death.  Mumps causes swollen salivary glands under the jaw, fever, headache and may lead to meningitis (infection in the covering of the brain and spinal cord), encephalitis (brain swelling), and inflammation of the testicles or ovaries and permanent deafness or death.  Rubella can cause serious problems during pregnancy including miscarriages, stillbirths, premature deliveries or birth defects.

Varicella:  Protects against varicella, also known as chickenpox.  Chickenpox can cause infection of the blisters, bleeding problems, encephalitis (brain swelling), pneumonia (infection in the lungs) .

HepA:  Protects against hepatitis A, a virus that attacks the liver.  There may be no symptoms or a slight fever and yellowish color to the skin.  It may also cause vomiting and stomach pain.

HPV:  Human papillomavirus is a common virus in patients in their teenage years.  It is the major cause of cervical cancer in women and genital warts in women and men.

MCV4:  Meningococcal conjugate vaccine protects against an infection that can lead to meningitis (infection in the covering of the brain and spinal cord).

This document is for informational purposes only, and should not be considered medical advice for any individual patient.  If you have questions please contact your medical provider.

 

I hope that you have found this information useful.  Wishing you the best of health,

Scott Rennie, DO

Blog: https://doctorrennie.wordpress.com

Health Resource Links

shutterstock_146913077The following is a selected list of homepages for associations and organizations that provide specific disease, research, and assistance information.

National Associations (Disease, Research, and Assistance)

Alzheimer’s Association
Links to caregiver resources, news, medical & research development, public policy information & related resources.

American Cancer Society
Fact sheets, statistics, etc from the American Cancer Society.

American Diabetes Association
Links to recommendations and patient education information, diabetes education programs. Site is searchable by state and topic.

American Heart Association
Guidelines and fact sheets, including “Heart Disease & Stroke Guide”.

American Liver Foundation
Provides information about liver in health and disease, research funding, and patient related information.

American Lung Association
Consumer site “designed to give you easy access to information on a variety of lung health issues, including asthma, asthma and children, smoking and tobacco control, lung disease and related diseases, lung health for diverse communities, and environmental health.”

American Red Cross
Information about the Red Cross, including its services and opportunities to be involved.

Amyotrophic Lateral Sclerosis (ALS) Association
Commonly known as Lou Gehrig’s disease, this is the national not-for-profit voluntary health organization dedicated solely to the fight against ALS.

Arthritis Foundation Home Page
Fact sheets, news releases, resource room and links to other sources.

Crohns and Colitis Foundation of America
The most comprehensive information about inflammatory bowel disease (IBD) on the Internet.

Cystic Fibrosis Foundation
A resource of information with links to local CF chapters.

Epilepsy Foundation of America
Working for children and adults affected by seizures wholly dedicated to the welfare of people with epilepsy.

Hospice Association of America
Representing more than 2,800 hospices and thousands of caregivers and volunteers who serve terminally ill patients and their families.

Leukemia & Lymphoma Society
Formerly known as The Leukemia Society of America, it provides links to information on leukemia, myeloma and lymphoma.

Lupus Foundation of America
Extensive site containing information on chapters, current Information, FAQ’s, and links to other authoratiative sites.

Muscular Dystrophy Association
A searchable database listing 230 MDA clinics across the country, as well as numerous publications concerning neuromuscular diseases, “Ask the Experts” about current research developments and medical management of neuromuscular conditions.

Muscular Dystrophy Association
Supports research and education of kidney and urinary tract diseases.

National Lymphedema Network
Provides education and guidance to lymphedema patients, health care professionals and the general public on the prevention and management of primary and secondary lymphedema.

National Mental Health Association
Promotes mental health, preventing mental disorders and achieving victory over mental illnesses through advocacy, education, research and service.

National Multiple Sclerosis Society
Presents information on this chronic, often disabling disease of the central nervous system while putting you in touch with the local chapter near you. In Western Washington, it is The Greater Washington Chapter.

National Parkinson Foundation
Researching to find the cause and cure of this disease and other neurological disorders with information and referral.

National Stroke Association
Promotes national awareness of stroke risk factors and symptoms in reducing the incidence and impact of stroke.

International Resources

International Committee of the Red Cross
Charged to protect the lives and dignity of victims of war and internal violence and to provide them with assistance.

International Society for Infectious Diseases (ISID)
Composed of individual members from over 155 countries around the world, it is committed to effective research, patient care, and long-term solutions and control of infectious diseases throughout the planet.

Pan American Health Organization
International public health agency working to improve health and living standards of the countries of the Americas.

World Health Organization
Acts as the directing and coordinating authority on international health work.

AMA: Supreme Court Decision Protects Much-Needed Health Insurance Coverage for Millions of Americans

Statement attributable to:
Jeremy A. Lazarus, MD
President, American Medical Association

 

The American Medical Association has long supported health insurance coverage for all, and we are pleased that this decisionPDF FIle means millions of Americans can look forward to the coverage they need to get healthy and stay healthy.

“The AMA remains committed to working on behalf of America’s physicians and patients to ensure the law continues to be implemented in ways that support and incentivize better health outcomes and improve the nation’s health care system.

“This decision protects important improvements, such as ending coverage denials due to pre-existing conditions and lifetime caps on insurance, and allowing the 2.5 million young adults up to age 26 who gained coverage under the law to stay on their parents’ health insurance policies. The expanded health care coverage upheld by the Supreme Court will allow patients to see their doctors earlier rather than waiting for treatment until they are sicker and care is more expensive. The decision upholds funding for important research on the effectiveness of drugs and treatments and protects expanded coverage for prevention and wellness care, which has already benefited about 54 million Americans.

“The health reform law upheld by the Supreme Court simplifies administrative burdens, including streamlining insurance claims, so physicians and their staff can spend more time with patients and less time on paperwork. It protects those in the Medicare ‘donut hole,’ including the 5.1 million Medicare patients who saved significantly on prescription drugs in 2010 and 2011. These important changes have been made while maintaining our American system with both private and public insurers.”

Healthcare Resources for Patients – Do You Trust All The Medical Information Out There?

shutterstock_172524281With all the information out there on the internet, in magazines, books, newsletters, radio, hotlines and on television, sometimes it’s hard to know where to go for information to learn about health and diseases on your own.  I encourage most of my patients to use technology, but I want them to have a list of resources to search when they are looking for information and be able to judge whether it comes from a credible source.  A huge amount of information is available online, however sometimes it’s of variable quality and can be difficult for the patient to decide whether or not a particular source is credible.

I think it’s the medical providers responsibility to educate patients on how they can do their own research, because patients may not have:

1)   An understanding of the biology of the disease process

2)   Knowledge about how to determine if the information is credible based on the type of research study (i.e. case report, single randomized trial or double blinded trial with placebo).

3)   Skepticism about the information that may come from biased sources such as from a drug company, from authors with financial conflict of interests and intellectual zeal, or wish for personal aggrandizement.

4)   Familiarity with how a patient with the disease presents and the signs and symptoms of the illness

5)   An understanding how good scientific research done by well trained scholars in centers of academic excellence

Some hints on finding trustworthy information online:

1)   Was the website recommended from someone you trust, such as your physician, the National Institute of Health or A Medical Library Association?  I recommend using a trusted source of information rather than relying on a search engine and using the first or second webpage that comes up in the search.

2)   Sites such as the Mayo Clinic (http://mayoclinic.com) that display the seal logo on their page.

3)   Websites that are sponsored by medical schools, or the government

4)   If you type your question into a general search engine such as yahoo, or Google, use multiple sites and compare the information based on the criteria below.

How do you know if a website is good quality?  Here are some possible factors to consider:

1)   Who created the website?  Anyone can create a website or blog and the information all is printed and looks legit, but is it?  Is it a well known and respected organization or recommended site by someone you trust?

2)   What is the purpose of the website?  Consider who the intended audience is, and how it was created.

3)   What are the funding sources for the website?  Do the producers of the website have some financial interest or sell something that may bias the information presented on the site?

4)   Consider the date that the information was released.  Medical research is rapidly advancing and the information may be dated.  Look for a date that the site updated or posted the information.

5)   Consider the evidence when examining the treatment recommendations.

6)   Personal experiences of the authors may make for interesting reading material, but should be clearly marked as personal experiences and not be the only rationale for the recommendations.

7)   The author of the website or blog should be available for communication and response.

8)   The website should explain if there are conflicts of interest or limitations in the information provided and that the information does not replace contact with a medical provider or physician.

9)   If there are forums, bulletin boards or interactive chat rooms, be wary of who the participants are.

The Medical Library Association has created a set of criteria to help patients judge the quality of websites for themselveswww.mlanet.org/resources/userguide#3

The US Government has also created a guide called A User’s Guide to Finding and Evaluating Health Information on the webwww.healthfinder.gov

Books:  Some credible books that are produced by the government or medical schools include:

1)   Mayo Clinic Health Book, 4th Ed. New York Time Home Entertainment, 2009

2)   Harvard Medical School Family Health Guide, 1st Edition. New York; Simon and Shuster, 2005

3)   American Medical Association Family Medicine Guide, 4th Ed. Indianapolis, IN, Wiley 2004

Magazines:  Consumer Reports and American Family Physician publish information responsibly.  The information from the American Family Physician magazine is intended for medical providers and may use medical jargon that is less helpful for the average patient however.

Newspapers:  The New York Times and Washington Post have medical writers who are scientific backgrounds and often provider information in a very captivating way.

This document is for informational purposes only, and should not be considered medical advice for any individual patient.  If you have questions please contact your medical provider.

 

I hope that you have found this information useful.  Wishing you the best of health,

Scott Rennie, DO

Blog: https://doctorrennie.wordpress.com

A Healthy Poke: Demystifying the Science Behind Acupuncture

SEP 29 2011, 10:07 AM ET 442

ALICE G. WALTON – Alice G. Walton is a health-and-science journalist who writes on medical issues, particularly those related to the brain and behavior. She holds a Ph.D. in biopsychology and is an editor at TheDoctorWillSeeYouNow.com.

Many of us have started to embrace the use of alternative medicine, but acupuncture, with its qi, yin, and meridians, still raises eyebrows

While many practices in alternative medicine are slowly but surely making their way into the mainstream, acupuncture is one that still produces skeptical eyebrow raises. This phenomenon is partly due to linguistics. Scientists have worked to elucidate the mechanisms by which yoga, meditation, and various dietary interventions may work on the cells of the body, but there is something fundamentally more ancient-feeling about the language of acupuncture. Go to the NIH’s website on complementary and alternative medicine (NCCAM), and even here you’ll find a discussion that involves qi, yin, yang, and meridians.

Is it possible to discuss acupuncture in a way that makes sense to even the most Westernized brains? The short answer is yes — but with the caveat there there is no single unifying explanation for how it works. While acupuncture has been demonstrated to be useful in pain management and in treating the nausea and vomiting associated with chemotherapy, other uses have had more mixed results when studied scientifically.

Dr. Leena Mathew is an attending physician in Anesthesiology and Pain Medicine at New York Presbyterian Hospital/Columbia University Medical Center. She uses acupuncture as an “adjunct analgesic modality,” meaning that she uses it as a complementary treatment for pain in her patients should they require or prefer it. She and Dr. Josephine Briggs, director of NCCAM, discussed with us the most likely theories of the mechanisms behind acupuncture.

For pain management, one idea is that acupuncture may be working via the gate control theory, first outlined by Melzack and Wall in the 1960s. This theory suggests that pain is transmitted through small nerve fibers from the skin through the spinal cord and on up to the brain. Also present are larger fibers which normally send inhibitory signals to the small pain fibers, which essentially “gates” or prevents a pain signal from being set off. When a painful stimulus comes in, however, the activity in the small nerve fibers overwhelms the large ones, so inhibition is released and the gates of pain opened. Where does acupuncture come in? Theoretically, the needles are placed in positions to stimulate the large nerve fibers, so that the small — painful — ones are inhibited. Mathew says that the same logic theoretically underlies why rubbing your elbow after you bang it helps alleviate the pain: you’re stimulating the inhibition that quiets the pain.

Another possibility is that endorphins, the body’s famed “feel good” chemicals, are behind the effect of acupuncture on quelling pain. Mathew says that the happy little chemicals are released in response to a range of phenomena — distress, injury, running long distances, chocolate — and have the knack for acting like morphine on the body and brain. Studies have tracked levels of these molecules in the blood, and shown that acupuncture is linked to higher levels of beta-endorphin at the same time that patients are reporting decreases in their pain levels. Even more, when you inject people with the anti-morphine drug naloxone, the effects of acupuncture are reduced.

But other theories better explain why acupuncture has been shown to work well on the nausea and vomiting (PDF) associated with chemotherapy. In the 1950s, the nerve reflex theory was proposed, suggesting that the body’s periphery (the skin) is connected to the internal organs through a reflex called the viscero-cutaneous reflex. “If you stimulate the periphery with acupuncture needles,” explains Mathew, “you can change the blood flow pattern to the stomach and abdomen, which could explain the effect on nausea and vomiting.”

Acupuncture may also have an effect on the body’s stress response system, otherwise known as the hypothalamus-pituitary-adrenal (HPA) axis, which could be why acupuncture patients report lower stress levels and anxiety after treatment, at least in the short term.

If you were wondering when the word “placebo” was going to enter the discussion, here it is — but it’s not what you think. What researchers now know about the placebo effect is that it isn’t some hokey “mind over matter” thing. The response is a robust, demonstrable physiological phenomenon, according to Mathew. When people are being “treated” with placebo, you can actually see the change in blood flow patterns in the cortices of their brains in fMRI. Some people are more responsive to the placebo effect than others, and there is no doubt that some of this effect is going on with acupuncture, and particularly heightened in placebo-sensitive individuals.

Which leads to the final theory about why acupuncture may work on certain conditions. The very presence of human touch may have a lot to do with acupuncture’s healing power, Mathew suggests. “This is therapeutic touch,” she says. “As Westerners, we’re disconnected from this. We don’t want to touch patients.” But just as a mother calms a child simply through her physical/emotional presence, having another human being exert a well-intentioned touch may, in its simplicity, also do a lot to alleviate pain. This effect may have to do with the alleviation of fear and anxiety, things we know account for a huge portion of our perception of pain.

Briggs adds to this idea by mentioning that some of the effects of acupuncture can also be seen when “sham” treatments like toothpicks are used, which can sometimes have an effect similar to acupuncture. This, she says, “tells us that a very important part of acupuncture’s effect is the ritual involved, which includes pressure, reassuring practitioners, and the patient’s expectation.” In other words, the act of acupuncture itself is at least partially what accounts for its effect.

She adds that we need to start asking different questions about acupuncture, and using different language to discuss is. For example, she says that “meridians were developed by a tradition of people who didn’t dissect human body — meridians are not good a scientific question. But, ‘How does the practice change our perception of pain?’ is a good question. It’s quite plausible that pain pathways are modulated by emotion, pill placebo, etc., so it’s not surprising that reassurance of ritual or expectation is at play here. ”

As Mathews points out, acupuncture is a “retrospective science, going on for 3,000 years. We know it works, we just don’t know why. It’s very hard to translate into Western language.” Still, it should be possible to do so, and we seem to have made some progress. Hopefully more researchers asking the right questions, and coming up with clever new techniques to address them, will help elucidate the mechanisms and unify the theories.

Image: REUTERS/Mike Cassese.

 

**Addendum

If you would like to locator an Acupuncturist/Oriental Medicine Provider in your area, one resource that I found helpful is the American Association of Acupuncture and Oriental Medicine Website:  http://www.aaaomonline.org/search/custom.asp?id=320

Scott Rennie, DO