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www.legendaryherbs.com (ph) 303-442-0144 [email protected] We are thrilled to bring you this issue of the Journal of Acupuncture and PG.4 Integrative Medicine (JAIM), formerly the California Journal of Oriental Medicine TRADITIONAL AND MODERN (CJOM). PHARMACOGNOSY: PERSPECTIVES FROM CHINESE As acupuncture finds its way into more hospitals and integrative medical settings, AND WESTERN HERBAL MEDICINE patient-focused care is no longer an ideal, but a new - and refreshing - reality. Dr. Eric Brand, L.Ac., PhD. Patients are beginning to rely not just on their doctor, but on a healthcare team, which may include a nutritionist, therapist, acupuncturist, chiropractor, and naturo- PG.8 path, just to name a few. USING ACUPUNCTURE TO TREAT CHEMOTHERAPY-INDUCED PE- Last Fall, our editorial team sat down to decide how we would bring this RIPHERAL NEUROPATHY expanded thinking to CJOM. The answers were clear: First, to introduce more Heidi Bartlett,L.Ac. integrative medical content, thereby drawing in readers from across all medical professions. Second, we would give CJOM a fresh look and feel that was modern PG.15 yet medical, while acknowledging our 20+ years in publication. Third, we would NEUROPUNCTURE: SOLIDIFYING choose a name that reflects the move towards integration. ACUPUNCTURE’S AUTHENTICITY Dr. Michael Corradino,DAOM, As you know, our country is facing an epidemic of mass proportion: the over-use, MTOM,L.Ac. over-prescription, and overdosing of opioids. We have devoted this issue to answering the question of how acupuncture and herbal medicine can address pain PG.18 management and the opioid crisis. The authors contained herein have written MOXIBUSTION THERAPY IN THE incredible articles detailing both their research and their experiences. We hope you TREATMENT OF RADIATION FI- learn from them and can apply what you learn to your own practices. BROSIS OF THE THROAT Dr.Bianca Di Giulio,DAOM,L.Ac. Acupuncture medicine has such a rich, detailed history and the best way to Dr. James Munson,DAOM,L.Ac. continue that history is to share our knowledge freely and willingly! PG.22 In health, AN INTERDISCIPLINARY PERSPEC- TIVE ON THE OPIOID CRISIS Dr. Jordan Wheeler, L.Ac. & Elena Roemer Jessica Wakeman Co-Editors-in-Chief PG.29 DISCUSSIONS ON GUI ZHI JIA LONG GU MU LI TANG: APPLICA- TIONS FOR TREATMENT OF TRAU- MA AND SUBSTANCE ABUSE Benjamin Zappin,L.Ac.

PG.32 “SHEN-OCIDE”: TREATING THE PSYCHOSPIRITUAL ASPECTS OF OPIOID ADDICTION WITH ACU- PUNCTURE AND CHINESE MEDI- CINE Mary Elizabeth Wakefield, L.Ac.,M. S.,M.M.,Dipl.Ac.,NCCAOM

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

Pictured left to right: Robyn “Ra” Adcock (Publisher) Dr. Jordan Wheeler Jessica Wakeman

MISSION STATEMENT The California State Oriental Medical Association (CSOMA) is a professional association of licensed acupuncturists and supporters of acupuncture, dedicated to the preservation, advancement and integration of the art, science, and practice of all branches of acupuncture medicine into the modern healthcare model, in a caring and ethical manner, thereby enhancing the health and well-being of the general public.

3 TRADITIONAL AND MODERN PHARMACOGNOSY: PERSPECTIVES FROM CHINESE AND WESTERN HERBAL MEDICINE by Dr. Eric Brand, L.Ac., PhD.

Editors in Chief The timeless human quest to dis- as bacteria and fungi that were Dr. Jordan Wheeler, DACM, L.Ac. cover natural products that can inaccessible to research before the Jessica Wakeman alleviate disease and suffering modern era. has caused pharmacognosy to be Executive Director & Publisher described as the “oldest modern A MULTIDISCIPLINARY SCIENCE Robyn “Ra” Adcock, L.Ac. science.”1 The use of plant, animal, and mineral products in the treat- Pharmacognosy has been a mul- Marketing Director ment of disease has been docu- tidisciplinary science throughout Kim Neuman, L.Ac. mented worldwide for thousands of history. The importance of plant- years, and trade in medicinal prod- based medicines has long caused Graphic Designer ucts between cultures dates back to pharmacognosy to be intricately Darren Samuel ancient times. Over the course of connected to botany. The close re- history, pharmacognosy has evolved lationship of these two disciplines Associate Editors considerably following advances was emphasized in the 1917 text Dr. Sharon Hennessey, DAOM, L.Ac. in disciplines such as taxonomy, Handbook of Pharmacognosy with Dr. Tamsin Lee DAOM, L.Ac. agronomy, and chemistry, and tre- the statement: “Vegetable drugs Michael Morgan, L.Ac. mendous diversity can be seen in are of vastly greater importance Ilana Murphy, L.Ac. the pre-modern approaches used and therefore a knowledge of bota- Emily Sablosky, L.Ac., CMT by different cultures to evaluate ny is necessary to an understanding and apply natural medicines. of pharmacognosy.”4 Indeed, prior Subscriptions to the development of Linnaean Published annually and distributed The word pharmacognosy, which taxonomy and plant classification nationwide to licensed acupunctur- is derived from the Greek words texts known as “floras,” most texts ists, allied medical professionals, “pharmakon” (drug) and “gno- dedicated to plant identification and students. sis” (knowledge), was first coined were “herbals” that also contained in 1811 by an Austrian physician details on the therapeutic activities Contact CSOMA at: named Johann Adam Schmidt.2 of plants.5 Today, taxonomic identi- 548 Market Street #68552 Traditionally, pharmacognosy fo- fication of medicinal plants is con- San Francisco, CA 94104 cused on the study of crude drugs sidered to be a fundamental step Phone/Fax: (800) 477-4564 of natural origin, encompassing in the authentication of medicinal Web: csomaonline.org aspects such as authentication materials.7 E-mail: [email protected] and quality control. In the modern era, pharmacognosy has expanded In addition to botany, the field of JAIM is a publication of the beyond traditional techniques such chemistry has had a major impact California State Oriental Medical as macroscopic identification and on traditional pharmacognosy. Association (CSOMA). All arti- microscopy, and advances in molec- Following the successful isolation cles represent the opinions of the ular biology and screening methods of morphine and other pure com- authors and do not necessarily to identify chemical constituents pounds at the beginning of the reflect the official policy of CSO- and therapeutic targets have trans- 19th century, the notion of active MA, unless this is clearly specified. formed the field.3 In recent years, constituents that could replicate The presence of an advertisement, new methods of drug discovery the effects of crude drugs attracted letter, or article in JAIM does not utilizing computer simulation mod- tremendous attention. While most constitute an endorsement of the els have been developed to com- official drugs listed in pharmaco- product or ideas represented there- plement the traditional process of poeias around the world primarily in. investigating potential new drugs consisted of plant-based crude based on ethnopharmacological drugs until the early 20th century, Copyright © 2018 by CSOMA observations. the modern concept of “drugs” in All rights reserved. NO part of this popular Western culture gradually publication may be reproduced, The concept of a “drug” has began to focus on natural or syn- stored in a retrieval system, or evolved over the course of hu- thetic active chemical constituents transmitted in any form or by any man history, and the discipline of rather than crude natural products. means, electronic, mechanical, pho- pharmacognosy has evolved along tocopying, recording, or otherwise, with it. The English word “drug” Today, chemistry remains indis- without prior written permission is derived from the word “dry,” pensable in pharmacognosy and from the publisher. JAIM strives reflecting the fact that drugs orig- is essential for quality control and to present readers with a fair, inally referred to dried medicinal new drug discovery. In recent years, balanced, and independent pub- plants. In addition to plant-based the multidisciplinary nature of mod- lication. For more information on drugs, mineral and animal products ern pharmacognosy has continued our policies regarding conflict of have been used as drugs by many to expand with the arrival of new interest, please contact the editor different cultures, and a number techniques, such as the use of DNA at [email protected]. of mineral and animal drugs were bar-coding for authentication or included in classical herbal texts the use of metabolomics for assess- ISSN 1090-1965 such as Dioscorides’ De Materia ing pharmacologic effects. Medica and the Divine Farmer’s Classic of Materia Medica (Shen Traditional and modern pharmacog- Nong Ben Cao Jing) from China. Al- nosy both emphasize the authenti- though some additional biological cation of medicinal materials and materials such as marine organisms the discovery of new drugs through and large fungi have traditionally research into crude drugs. How- been used as medicines for centu- ever, as the techniques to identify ries, modern pharmacognosy has crude drugs and to discover new expanded to investigate new drugs drugs have become more sophisti- derived from microorganisms such cated, pharmacognosy has evolved

4 TRADITIONAL AND MODERN PHARMACOGNOSY: PERSPECTIVES FROM CHINESE AND WESTERN HERBAL MEDICINE by Dr. Eric Brand, L.Ac., PhD.

to incorporate a range of disci- pharmacognosy. Additional ben- TRADITIONAL PHARMOCOGNOSY plines and tools that did not exist cao texts focused on recording IN THE WEST during the formative era of tradi- medicinal substances from specific tional pharmacognosy. Due to the geographic regions, such as the As in China, the study of crude vast number of natural substances Materia Medica of Steep Moun- drugs in the West preceded the that must be prioritized for investi- tainsides (Lu Chan Yan Ben Cao), formal development of pharmacog- gation, traditional pharmacognosy which catalogued local medicines nosy as a named scientific disci- is often informed by ethnophar- from the region around modern-day pline. Texts dedicated to medicinal macology, the traditional use of Hangzhou.7 Bencao literature also materials were first established in medicinal substances in indigenous includes texts dedicated to me- Europe in Greek and Roman times, cultures. By contrast, in modern dicinal processing, a practice that and many local and foreign me- pharmacology, the use of high significantly impacts the chemistry dicinals were described in ancient throughput screening techniques and therapeutic nature of medici- Western texts. In the Renaissance allows for the rapid screening of nal substances. However, although period, the arrival of printing thousands of substances in a short bencao literature remains a rich technology heralded a dramatic period of time, which expands the resource for traditional pharma- increase in the number of herbal number of plants that can be rap- cognosy, its global impact has long texts that were published, and the idly assessed. Aided by computer been limited by a language barrier literature began to diversify be- simulations and methods of match- because few ancient bencao texts yond the original foundations laid ing libraries of chemical structures have been translated into Western by Dioscorides. Texts in European to biochemical targets, modern languages. languages other than Latin began pharmacognosy has expanded the to proliferate, and with the age of possibilities for drug discovery, As can be seen from these exam- exploration and colonization of new making pharmacognosy less de- ples, traditional bencao literature territories, new herbal medicines pendent on researching substances contains valuable information on were introduced to Europe. with a cultural history of medicinal the authentication of medicinal use. materials, classification of natural Since the time of Theophrastus substances, and acquisition of new (a student of Aristotle), there has TRADITIONAL drug sources from the exploration been a close relationship between PHARMACOGNOSY IN CHINA of locally used plants by indige- the fields of botany and Western nous groups. While these devel- herbal medicine. This relation- In China, the discipline of tradition- opments arose historically prior to ship developed dramatically after al pharmacognosy was influenced the arrival of the modern science printed texts called “herbals” by exchange with Japan, where a of pharmacognosy, these features emerged in the late 15th century, number of new texts devoted to nonetheless illustrate a sophisti- and the relationship between early pharmacognosy emerged in the late cated level of knowledge regarding botanical and medicinal literature 19th century. In 1905, the Chinese the study of crude drugs. By ap- is described in detail in key histor- scholar Zhao Yuhuang studied in plying techniques such as chemical ical works such as Herbals, Their Japan and returned to emphasize analysis, laser micro-dissection, Origin and Evolution: A Chapter in pharmacognosy as a professor genetic testing and taxonomy, the History of Botany 1470-1670, in Beijing; his Qizhou Medicinal modern pharmacognosy is allowing written by Agnes Arber in 1912. Journal became the first Chinese traditional Chinese medical knowl- (5) Detailed botanical descriptions resource that organized materia edge to be systematically assessed were first found in herbals, which medica knowledge based on Latin using the scientific method. Chem- focused on plants that were used taxonomy.7 ical analysis allows the effects of medicinally; as the discipline of traditional processing methods on taxonomy developed, botanical de- While this era represents a mile- the chemistry of crude drugs to scriptions of plants moved beyond stone for the arrival of traditional be studied, and the integration of herbal medicines to focus on the pharmacognosy as a modern sci- bencao study and modern taxono- classification of all plants using the ence in China, many aspects rele- my has led to clarification regard- systematic approach that defines vant to traditional pharmacognosy ing the used plant species for many modern taxonomy. In a situation had been previously explored in medicinal materials described in that parallels the current state of Chinese bencao literature. For ex- ancient texts. While traditional pharmacognosy, taxonomy itself is ample, the Ming Dynasty illustrated pharmacognosy techniques such as divided into traditional and modern text Origins of the Materia Medica microscopy have long been essen- approaches; traditional taxonomy (Ben Cao Yuan Shi) was dedicated tial for determining the authenticity favors morphological identifica- to the morphological identification of crude drugs, modern techniques tion while modern taxonomy is of medicinal materials, and previ- such as combining laser micro-dis- also influenced by newer analytical ous works such as the Extension of section with LC-MS have advanced methods such as genetic testing the Materia Medica (Ben Cao Yan the discipline of microscopy by and chemotaxonomy. Yi) focused on the differentiation of determining where active constit- genuine vs. inauthentic medicinals.7 uents are concentrated within the Beyond botanical descriptions anatomical structures of botanical of the source plants, traditional In 1593 AD during the Ming Dy- materials. This research has sig- knowledge about crude drugs in nasty, the Compendium of Materia nificant implications for the qual- ancient Western herbal texts often Medica (Ben Cao Gang Mu) by Li ity assessment and production of featured discussions of growing Shizhen was published; featuring medicinal materials, and can also regions, harvest times, flavors and 1,892 medicinal substances, this help to resolve cases where the properties, as well as characteris- monumental text utilized a novel, traditional literature contains con- tics of different preparations, such two-tiered classification system flicting statements with regard to as tinctures, powders, syrups, etc. for organizing natural substances, medicinal quality.8 Following the invention of the mi- and remains a rich resource with croscope, microscopy was applied great relevance for traditional extensively in herbal authentica-

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

tion, and numerous discussions REFERENCES related to avoiding adulterants are found in the Western herbal 1) de Pasquale, A, Pharmacognosy: literature. In the 19th century, the oldest modern science, J Eth- the discipline of medicinal chem- nopharmacol. 11(1):1-16 (1984) istry advanced considerably, and pure compounds began to become 2) Heinrich, Fundamentals of Phar- incorporated into Western pharma- macognosy and Phytotherapy, Else- copoeia texts (which had previously vier Health Sciences, p. 19, 2004 only contained references to crude Eric Brand is a Chinese medicine drugs and extracts). 3) Sarker S, Pharmacognosy in mod- practitioner with a passion for ern pharmacy curricula, Pharma- materia medica and herbal quali- Following the successful isolation cogn Mag. 8(30): 91–92 (2012) ty discernment. After graduating of pure compounds with medicinal from the Pacific College of Oriental efficacy, the discipline of phar- 4) Wall, Handbook of Pharmacogno- Medicine in 2003, Eric spent over macognosy in the West gradually sy, Mosby, St. Louis, p. 15, 1917 a decade pursuing academic and began to shift its focus from eval- clinical opportunities in Asia. He uating the quality of crude drugs 5) Arber, Herbals: Their Origin and earned his PhD at the School of based on organoleptic properties Evolution, Cambridge University Chinese Medicine at Hong Kong to identifying the active compo- Press, London, 1912 Baptist University in the field of nents within crude drugs through Chinese herbal pharmacy, and he chemical analysis. Just as the 6) Zhao ZZ, Hu Y, Liang ZT, Yuen J, remains engaged in teaching and discipline of botany initially began Jiang ZH, Leung K, Authentication research. Eric is the Deputy Gener- with a focus on plants with me- is Fundamental for Standardization al Manager for Beijing Tongrentang dicinal use in traditional culture of Chinese Medicines, Planta Med (USA), and serves as a TCM advisor and then expanded to focus on 72(10): 865-874 (2006) to the American Herbal Pharmaco- the classification of all plants, the poeia. He has written or translated field of pharmacognosy has ex- 7) Zhao et al., Chinese Medici- a variety of modern and classical panded beyond its original focus nal Identification: An Illustrated texts and peer-reviewed articles, on ethnopharmacology, incorporat- Approach, Paradigm Publications, and is the founder of the granule ing new approaches such as high Taos, New Mexico, 2014 company Legendary Herbs. throughput screening to search for novel and undiscovered active 8) Yi L, Liang ZT, Peng Y, Yao X, ingredients in a progressively wider Chen HB, Zhao ZZ. Tissue-specific range of plants. Nonetheless, it metabolite profiling of alkaloids in is estimated that only about 6% of Sinomenii Caulis using laser micro- higher plants have been screened dissection and liquid chromatogra- for biologic activity, and only about phy-quadrupole/time of flight-mass 15% have been evaluated phyto- spectrometry. Journal of Chroma- chemically.9 tography A., 1248: 93-103 (2012)

The process of discovering new 9) Fabricant DS, Farnsworth NR. medicines and improving the quali- The value of plants used in tradi- ty control of existing crude drugs is tional medicine for drug discovery. a monumental task that has occu- Environmental Health Perspectives, pied humanity since the dawn of 109(1):69–75 ( 2001) written history. In the modern era, enhanced methods of screening and testing have greatly speeded the acquisition of new knowledge, but many known crude drugs remain poorly understood and many potential new drugs are yet to be discovered. Likewise, a tremendous amount of traditional cultural knowledge relevant to the field of pharmacognosy has been recorded around the world, but only a tiny fraction of this knowledge has been disseminated worldwide in multiple languages. Consequently, there is a vast amount of knowledge that remains to be discovered through the application of both traditional and modern pharmacognosy, and both aspects of the field have a bright future and limitless horizons.

USING ACUPUNCTURE TO TREAT CHEMOTHERAPY-INDUCED PERIPHERAL NEUROPATHY by Heidi Bartlett, L.Ac.

ABSTRACT Background on Chemotherapy and to tumors of the breast, head or Chemotherapy-Induced Peripheral neck that we see now. The theory Chemotherapy-induced peripheral Neuropathy is a tumor develops when there is neuropathy (CIPN) affects 30%-70% tissue proliferation due to qi and of chemotherapy patients, some Some studies report an incidence blood accumulation.10 describing it as the most troubling as high as 70% of patients experi- side effect. Symptoms include ence CIPN, but others report 30% Cancer can occur due to several numbness, tingling and burning to 40%.4 CIPN negatively affects a factors such as invasion of exter- pain in the hands and feet. This is a patient’s quality of life. CIPN was nal pathogens, inappropriate diet, qualitative systematic review iden- reported by one-third of patients as emotions, and a combination of tifying acupuncture clinical trials their most troubling cancer-related phlegm with qi and blood stag- treating CIPN. Human research with side-effect.”4 It may also require nation.10 Also, “deficiency and a control group from any geograph- chemotherapy dose reduction or depletion of the zang fu organs is ic location written in the English cessation resulting in a higher an inevitable outcome of various language were included. Searches morbidity and mortality.5 CIPN pathological factors and at the were done on PubMed, Cochrane may persist or even intensify long same time is a prerequisite for the Reviews, and article reference lists. after chemotherapy treatments are development of cancer.”10 Of the six studies included, half completed.6 CIPN adds an average found a benefit to acupuncture, of $17,344 in healthcare costs per Background on Peripheral while the rest found no benefit or patient per year compared to those Neuropathy from a Traditional even increased pain. Key results without these symptoms.7 Chinese Medicine Perspective suggest avoiding electroacupuncture during chemotherapy. Im- The peripheral nervous system is As chemotherapy was not practiced provements were found in studies most susceptible to the damaging in ancient China, the only way to using auricular acupuncture, and effects of cytotoxic and biologic find TCM treatments for CIPN is to objective nerve conduction velocity agents used to treat cancer. “The look at the condition’s symptoms. measurements. Small sample sizes chemotherapy agents most com- Examples include relating it to wei and mixed results warrant further monly causing neuropathy are zheng or wilting condition; ma mu research before making defini- taxane (paclitaxel, docetaxel), vinca as the experience of numbness and tive treatment recommendations. alkaloids (vincristine), platinum tingling; and bu ren describing in- Standardized point selection and compounds (cisplatin, carboplatin), sensitivity or lack of feeling.11 measurement scales would help to proteasome inhibitors (bortezo- compare groups. Western medi- mib), and antiangiogenic com- METHOD cine has few effective treatments, pounds (thalidomide).”4 The most making acupuncture an attractive common symptoms of CIPN include The purpose of this study is to alternative. painful paresthesia in the hands determine whether acupuncture is and feet, allodynia, numbness, and an effective treatment for CIPN. INTRODUCTION cold hypersensitivity.4 This is a qualitative systematic review including human clinical Background on Cancer from a Western medicine poorly under- trials with a control group written Western Medical Perspective stands the pathophysiology of in English. Because there is less CIPN, and as a result, treatments research available for acupuncture, “Cancer is a group of diseases to prevent it are inadequate.5 there will be no limit to study inclu- characterized by the growth and CIPN neurotoxicity involves DNA sion based on publishing date. In spread of abnormal cells. If the damage, mitochondrial toxicity, contrast, research regarding CIPN spread is not controlled, it can re- oxidative stress, and ion chan- mechanisms and incidence will be sult in death.”1 The cause of many nel remodeling which can lead to limited to reports published after cancers is unknown. However, many apoptosis (cell death) in the pe- 2013 because after 5 years, system- types of cancer can be caused by ripheral nervous system neurons.8 atic reviews become out of date lifestyle choices such as smoking Once CIPN is established, Western due to new evidence of therapeutic tobacco or being overweight.1 On treatment options are also limited.5 effectiveness.12 Outcomes identify the other hand, some cancers are As a result, there is an urgent need how acupuncture affects CIPN pain, caused by genetic mutations, hor- for complementary and alternative numbness and tingling by measur- mones and immune conditions.1 medicine.9 ing pain, quality of life, and nerve conduction velocities. Research In the U.S., an estimated 1.68 mil- Background on Cancer from a trial articles will be searched by the lion new cancer cases were expect- Traditional Chinese Medicine primary author on PubMed and the ed to be diagnosed in 2016.1 In Perspective Cochrane Reviews database using the U.S., approximately 41 out of the following search terms: acu- 100 men and 38 out of 100 women During the 16th to the 11th centu- puncture, Traditional Chinese Medi- will develop cancer during their ry B.C., inscriptions on bones and cine, TCM, alternative medicine, lifetime.2 In the U.S., nearly 14.5 tortoise shells mentioned the word neuropathy, CIPN (chemothera- million people were living beyond liu or tumor.10 According to the py-induced peripheral neuropathy), a cancer diagnosis in 2014, and Zhen Zi Tong10 and Shuo Wen Jie and chemotherapy. this number is expected to rise to Zi dictionaries,10 the word zhong almost 19 million by 2024.2 (swelling) was a type of abscess, Excluded research consists of case where liu meant “to flow.” When studies, protocols without results, The economic impact of this dis- combined, zhong liu meant swol- articles, surveys, and unpublished ease is also staggering. In 2014, len tumor or neoplasm.10 In a book data, as well as research on TENS U.S. total cancer expenses totaled called the Zhou Li compiled in the (transcutaneous nerve stimulation), $87.8 billion according to the Qin dynasty (221-207 B.C.), doctors vitamins, supplements, and herbs. Medical Expenditure Panel Survey treated a malignant swollen sore Acupuncture trials with bee venom (MEPS).3 without ulceration10 – very similar injections will be excluded, as us-

8 ing hypodermic needles are outside the California acupuncture scope of practice.13 Research studies on neuropathy due to diabetes, autoimmune disorders, genetic disorders, human immunodeficien- cy virus (HIV), or trauma will be excluded as they have a different pathogenesis from CIPN.

RESULTS SF), in which pain is rated on a plained of CIPN, making this more scale of 0 to 10. It consists of nine specific scale appropriate for the Background on CIPN questions assessing pain severity included research studies. Another Severity Measurements and its impact on daily functions.17 variation of this questionnaire is Although originally designed to the FACT-Taxane with additional Comparing studies is difficult, since evaluate diabetic neuropathy, the items specific to taxane such as there does not seem to be a consis- TNS (Total Neuropathy Score) is arthralgias, myalgias, and skin dis- tent standard scale to measure the now also used to evaluate CIPN coloration.19 stage and severity of CIPN. Gener- pain.18-19 In addition to the patient’s ally, three different ways were used subjective report, this scale also in- The U.S. Department of Health and to determine improvement: pain, cludes objective measures such as Human Services, National Insti- quality of life, and nerve conduc- pin prick, vibration threshold and tutes of Health, National Cancer tion velocities. nerve conduction studies. The TNSc Institute22 devised yet another way is a version of the TNS scale de- to measure treatment side effects. First, there were several scales signed to measure only the clinical Originally called the Common Tox- used to measure pain within these signs and symptoms of CIPN.18-19 icity Criteria (CTC), it is now known studies. The most common was as the Common Terminology Crite- the VAS (visual analogue scale),14 There were several scales used to ria of Adverse Events (CTCAE). The measuring a patient’s subjective measure changes in quality of life. National Cancer Institute defines experience of pain utilizing a The FACT-GOG-Ntx (Functional As- an adverse event (AE) as any side questionnaire about pain intensi- sessment of Cancer Therapy/Gyne- effect due to the medical treatment ty. These studies generally used a cologic Oncology Group/Neurotox- rather than the disease. This scale numerical scale from 0 to 100 with a icity questionnaire) was used most measures the AE as a grade 1 to 5, lower number indicating less pain, often. A predecessor questionnaire where grade 1 is considered mild, and a higher number indicating was the FACT-G (Functional Assess- and grade 5 results in death. more intense pain. In this review, ment of Cancer Therapy – General), the NRS (numerical rating scale) developed to identify a cancer sur- The final quality of life criteria measures pain similarly to the VAS, vivor’s quality of life. This scale is developed by the European Organi- but with a scale of 0 to 10. The a subjective patient questionnaire zation for Research and Treatment neuropathic pain scale (NPS) is also with 28 items identifying the state of Cancer is the Quality of Life a subjective patient questionnaire of illness and physical capabili- Questionnaire (EORTC-QLQ-C30). consisting of 10 items designed ties, as well as the patient’s social This model measures the patient’s to specifically address neuropath- and emotional state.20 Building functionality – physical, role, ic pain such as reaction to light on this previous scale, the FACT/ cognitive, emotional and social. It touch, timing, intensity, and quality GOG-Ntx19,21 was developed for also measures symptoms such as fa- of the pain.15-16 Another subjective women diagnosed with gynecologic tigue, pain, nausea, and vomiting. patient questionnaire designed to malignancies who were treated with Finally, it has a scale to evaluate evaluate cancer pain, is the Brief neurotoxic drugs such as taxanes the patient’s overall health and Pain Inventory – Short Form (BSF- and platinum. These patients com- quality of life.23 It too, has supple-

9 USING ACUPUNCTURE TO TREAT CHEMOTHERAPY-INDUCED PERIPHERAL NEUROPATHY (CONT.) by Heidi Bartlett, L.Ac.

ments to make it more specific to malities in mixed, motor or sensory acupuncture, the neuropathy was the disease being measured, such nerves by electrically stimulating not related to chemotherapy, the as the QLQ-CIPN2024 adding ques- nerves with small safe pulses over acupuncture treatment plan tions specific to CIPN. Similarly, the limbs and then measuring the included injecting pharmaceutical the QLQ-OV28, designed for wom- results.27 Within the category of derivatives into acupuncture points, en diagnosed with ovarian cancer, NCV, two types of nerve velocities the patients were not human, the adds scales regarding the patient’s are measured – motor nerve con- study was not written in English, body image, sexuality, attitude to duction velocity (MCV) and sensory there were duplicated studies, the the disease or treatment, as well as nerve conduction velocity (SCV) as study did not have a control group, other chemotherapy-related side a way to gauge CIPN severity. or they were not relevant. After effects like peripheral neuropathy, detailed evaluation, 6 studies were hormonal complaints, and digestive REVIEW OF THE RESEARCH included in the review for treating issues.25-26 CIPN with acupuncture. For an al- After screening titles and/or ab- phabetical summary of the clinical The third type of CIPN evaluation stracts, 14 articles were excluded studies see Table 2. related to nerve conduction veloc- for the following reasons: the focus ities (NCV) to identify any abnor- was on an intervention other than

Overall, there were few studies to while others noted a decrease Alemi et al. (2003) review, treating a fairly small num- in pain and improved nerve con- ber of patients during a relatively duction velocities. Of note, two A study by Alemi, Rubin, Pich- short period of time. This makes studies using electroacupuncture ard-Leandri, Fermand-Brule, Du- it difficult to generalize results to (EA) during chemotherapy infusions breuil-Lemaire and Hill29 evaluated the overall CIPN patient popula- found the treatment increased auricular acupuncture compared to tion. Also, peripheral nerves take CIPN pain, suggesting EA may not sham auricular acupuncture, as well a long time to grow after injury, be beneficial during chemothera- as a control group receiving ear growing only 2 mm to 4 mm per py. Out of the six studies included, seeds. The goal for having two sep- day.28 Therefore, a longer treat- two took place while patients were arate control groups was to identify ment window may be necessary to still receiving chemotherapy, while whether inserting needles at invalid realize results. For overall results the remaining four took place after acupuncture points was a valid con- of acupuncture treating CIPN, some patients were completely finished trol. This study randomly assigned studies found no difference be- with chemotherapy 90 patients into three groups. For tween the control and acupuncture, the acupuncture groups, stainless some found the pain increased, steel needles were implanted into

10 the ear, and the patients were puncture points so it was included increase in neuropathy. Also, in instructed to record when the in the review. This research studied Japanese acupuncture, the treat- needles fell off. They received a 104 multiple myeloma patients who ment depths are very shallow, so treatment once a month for three had completed chemotherapy. Over there is a chance the control group months. An electronic voltmeter 84 days, patients received a total received some benefit from the was used to find ear points eliciting of 10 acupuncture treatments. The treatment. In addition, the short an electric response. The two con- cycle began with treatments daily treatment length could have influ- trol groups received treatments at for three days, then every other enced the results. At the end of placebo points – one group receiv- day for 10 days, then this treatment the study, there were no significant ing needles, the other receiving ear cycle repeated after 28 days for CIPN differences between the sham seeds. Overall, this study adhered three cycles. In conjunction with and acupuncture groups. closely to STRICTA guidelines, with the acupuncture treatment, pa- the exception of identifying the tients received 500 μg methylcobal- Rostock et al. (2013) acupuncturist qualifications. This amin injections every other day for last item may not be as relevant, 20 days, followed by two months of Rostock, Jaroslawski, Guethlin, since the points were determined oral methylcobalamin three times Ludtke, Schröder, and Bartsch35 by electrical response. After 60 a day. The control group received conducted a four-arm randomized days, 79 patients completed the the same methylcobalamin regimen trial evaluating EA’s effectiveness trial, with the acupuncture group without acupuncture. Methylco- to treat CIPN. In Germany, where demonstrated improvements with balamin, an active form of Vitamin it was conducted, hydroelectric a decrease in VAS pain scores. B12, is thought to improve nerve baths and vitamin B supplements Contrary to expectations, the two conduction and promote regen- are used to treat neuropathy. The placebo groups had no effect as a eration of injured nerves.33 The study randomly assigned 60 pa- result of their treatments. report closely adhered to STRICTA tients who had completed chemo- guidelines, but needed to discuss therapy into four treatment groups: Greenlee, et al. (2016) the TCM diagnosis, type of nee- EA, hydroelectric baths, vitamin B dles used, and whether the needles complex, and placebo. Patients in The study by Greenlee and col- were stimulated after insertion. the EA group received a total of leagues30 researched whether After treatment, the acupuncture seven to nine total treatments over acupuncture could prevent CIPN in plus methylcobalamin group expe- a three-week period. The hydro- breast cancer patients undergoing rienced significant improvements in electric bath group dipped either taxane chemotherapy. This study pain realizing an 85.7% reduction their arms or legs, depending on included 63 women who received in VAS pain scores compared a pain which limbs had CIPN, up past the 12 weekly treatments and were reduction of 77.6% in the control elbow or knee joint respectively randomly assigned to two groups – group. Finally, the report appears for 15 minutes with a current of 50 either electroacupuncture or sham to contradict itself on the MCV val- Hz in the water. In the vitamin B electroacupuncture as the control. ues – saying there was no change in protocol, patients ingested three The electroacupuncture group the acupuncture group, then later high dosage capsules, containing received 2 Hz treatments based reporting there was a significant 100 mg of thiamine nitrate and on a Traditional Chinese Medicine change. 100 mg of pyridoxine hydrochlo- (TCM) diagnosis of qi and blood ride, each day for three weeks. The deficiency and stagnation. The Lu et al. (2012) placebo group followed the same sham acupuncture group received regimen, but ingested capsules treatment using Park Sham collaps- The next pilot study by Lu and containing lactose. There were ible needles which touched but did colleagues34 examined how acu- some limitations to this study. not penetrate the skin.31 While the puncture affects quality of life for From a STRICTA perspective, it design of the study closely match- women with ovarian cancer. The was missing the TCM rationale for es STRICTA guidelines, the short trial treated a total of 21 patients treatment, needles used, and the amount of time patients received at two cancer centers who were re- needle depth. The outcome was treatment may hamper positive ceiving chemotherapy at the time. measured using the NRS pain scale, results. The outcome measures in- Patients received a total of 10 acu- and the NCI-CTC scale but found cluded the BSF-SF, FACT/GOG-Ntx, puncture treatments two to three no significant difference between FACT-Taxane, and NPS scales. Ac- times a week over a total of 21 the treatment groups. The authors cording to the BSF-SF evaluations, days. The active acupuncture group noted the patient’s pain scores for at 16 weeks, the sham acupuncture was treated with needles at a depth all groups were low at the begin- group pain scales reverted to their of 10 mm on recognized acupunc- ning of the study, leaving little baseline level, while the elec- ture points, as well as 25 Hz EA on room for improvement. Patients troacupuncture group’s pain was at least two points on the patient’s also received other treatments such actually getting worse, suggesting legs. In contrast, the control group as sport therapy, physiotherapy and that patients should not receive EA received needles that did not cor- massage at the same time which while getting chemotherapy treat- respond to acupuncture points, and could be part of the reason placement for taxane. The other scales were needled to a depth less than bo groups did so well. The placebo showed no measurable difference 0.2mm. This study closely followed group may have also fared better between the two groups. STRICTA guidelines, except it did because 88% started the study with not mention the acupuncturist paresthesia – compared to 100% of Han et al. (2017) qualifications. The outcomes were the EA group. Although not men- measured using EORTC-QLQ-C30 tioned in the study, the electric A study conducted by Han and col- and EORTC-QLQ-OV28. The pa- current in the hydroelectric bath leagues32 examined the use of acu- tient’s neuropathy was measured could have a similar effect to EA. puncture and methylcobalamin to 30 minutes after treatment, so any treat bortezomib-induced periph- tingling, or numbness increase felt Schroeder et al. (2012) eral neuropathy (BIPN). This study at that time could have been part did not include injections into acu- of the treatment rather than a true Schroeder, Meyer-Hamme, and

11 USING ACUPUNCTURE TO TREAT CHEMOTHERAPY-INDUCED PERIPHERAL NEUROPATHY (CONT.) by Heidi Bartlett, L.Ac.

Epplée36 published a pilot study such as Alimi et al.29 using the elec- by typically showing a decreased investigating whether acupunc- tronic voltmeter to select auricular amplitude in sensory nerve action ture could improve NCV for CIPN points, or Schroeder et al.36 and potentials.4 However, Stubblefield patients. This study included a Han et al.32 choosing NCV as an and colleagues argue that nerve total of 11 patients, with a self-se- objective outcome measurement. conduction studies correlate poorly lected control group who refused It would be interesting to do a me- with subjective patient reports and acupuncture. Patients in the acu- ta-analysis of the NCV studies. produce inconsistent findings, but puncture group received a total of they do note that patients tend to 10 treatments over the course of For the studies utilizing EA, none underreport their symptoms.19 In three months. The research closely described their reasoning for the contrast, the other studies used adhered to STRICTA guidelines, Hz setting or the treatment length largely subjective measurements except omitting the brand of nee- of time. For instance, Greenlee et to determine outcomes that may dle used. In addition, the groups al.30 used 2 Hz for 30 minutes, Lu et affect the ability to definitively were not randomly assigned, but al.34 used 20-25 Hz for 30 minutes, determine results. Cavaletti et al.,40 instead self-selecting. Outcomes and Rostock et al.35 used 50 Hz for and Brewer et al.,41 in separate were measured by NCV, with the 15 minutes. Research shows that research papers, noted patient-de- acupuncture group demonstrating enkephalin, endorphin, and endo- rived questionnaires and physi- improvement after follow-up at six morphin are released with EA of cian-based grading scales suffer months post-treatment, suggesting 2 Hz, while dynorphin is released from subjectivity and inconsistency. that acupuncture has a positive with a frequency of 100 Hz.37 These effect on CIPN. The length of time four peptides are an essential way Because there is little Western for follow-up is a strength of this that EA mediates pain in the cen- medicine can offer for pain relief or study compared to the others in tral nervous system.37 By combining prevention of CIPN, and there has this review, given the time it takes the 2 Hz and 100 Hz frequencies, been some evidence acupuncture for nerves to regenerate. all four neuropeptides are released can benefit these patients, there is in order to provide the greatest a case to consider acupuncture for DISCUSSION short-term therapeutic effect to re- this condition. In addition, acu- duce pain.37 Silva, Silva, and Prado puncture done by trained practi- After reviewing the six included suggest 100 Hz EA may be helpful tioners is generally a safe proce- studies, it is difficult to make broad in preventing pain, while 2 Hz does dure, and the number of adverse generalizations about the out- not.38 Therefore, future studies of events relating to it is below that comes. Three studies showed im- EA may want to investigate 100 Hz of common medical treatments.42-43 provement after acupuncture (Alimi EA to prevent CIPN, while alternat- et al.,29 Han et al.,32 and Schroeder ing 2 Hz and 100 Hz EA for existing CONCLUSION et al.36), while three showed either CIPN. In addition, sessions should no difference from the control strive to be at least 20 minutes, These studies demonstrated mixed group, or increased pain (Greenlee because the “analgesic effect of results, highlighting a great need et al.,30 Lu et al.,34 and Rostock et acupuncture has a slow onset, and for additional research to deter- al.35). Generalizing the results is reaches a peak after 20 minutes.”39 mine whether acupuncture has a also hampered by the small sam- Also, any future studies should benefit in treating CIPN. Based ple sizes in each of these studies. take care to administer a quality of on these few studies, acupuncture Another challenging part of evalu- life or pain questionnaire prior to may provide a benefit in improving ating these studies overall is that each individual EA treatment, since NCV, and auricular acupuncture the patient population is heteroge- the vibration and treatment itself appears to be beneficial. However, neous – some were treated during could temporarily increase pain it appears EA should be avoided chemotherapy, while others only and affect results. Keeping in mind while the patient is currently under- after chemotherapy was completed. the limitations of the available going chemotherapy. New research Future research should also consid- research, the data suggests avoid- should include large, multi-site er studies over a longer period of ing EA while the patient is currently trials with a defined protocol. From time due to the time it takes nerves receiving chemotherapy treatment, a Western medicine perspective, to regenerate. since two studies (Greenlee et more research needs to be done al.,30 and Lu et al.34) mentioned it to identify the cause of peripher- Each study used a different point potentially increased pain. It would al neuropathy and work towards prescription, and only one study, by also be interesting to research the a global measurement scale so Greenlee et al.,30 mentioned a TCM appropriate estim frequency for outcomes from research trials can diagnosis or rationale for why the nerve regeneration. be more easily compared with more points chosen. While a diagnosis of definitive conclusions. Finally, qi and blood stagnation along with Based on three of the studies, there because Western medicine lacks some deficiency might be straight- is evidence that acupuncture can effective treatments, the low risk of forward in these cases, the organ help improve CIPN pain. Theoreti- acupuncture treatments, and some affected by cancer may change the cally, the study by Alimi et al.29 had evidence pointing to its ability to treatment protocol. This makes it positive results because treatments improve nerve conduction velocity, difficult to determine an optimal lasted longer since stainless steel acupuncture should be considered point prescription to treat CIPN. needles were retained in the ear, in as a complementary treatment for addition to customized treatments patients experiencing CIPN. In addition, each study used a for each patient. One other inter- different scale to measure the esting result, the two studies (Han outcome, making it difficult to do et al.,32 and Schroeder et al.36) us- direct outcome comparisons, espe- ing objective measurements of NCV cially since the scales are largely both demonstrated improvements subjective. The most promising as a result of the acupuncture inter- studies had an objective way to vention. Nerve conduction studies choose the acupuncture points, are the standard to measure CIPN

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Oncology Nursing. 2016;20:144– Clinical Oncology: Official Journal 2012;1-10. 151. of the American Society of Clinical Oncology. 2003;21:4120–4126. 8) Kerckhove N, Collin A, Condé S, 20) Cella DF, Tulsky DS, Gray G, et Chaleteix C, Pezet D, Balayssac D. al. The Functional Assessment of 30) Greenlee H, Crew KD, Cap- Long-term effects, pathophysiolog- Cancer Therapy Scale: Develop- odice J, et al. Randomized sh- ical mechanisms, and risk factors of ment and validation of the general am-controlled pilot trial of weekly chemotherapy-induced peripheral measure. Journal of Clinical Oncol- electro-acupuncture for the pre- neuropathies: A comprehensive lit- ogy: Official Journal of the Amer- vention of taxane-induced periph- erature review. Frontiers in Pharma- ican Society of Clinical Oncology. eral neuropathy in women with cology. 2017;8(86):1-17. 1993;11:570–579. early stage breast cancer. 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13 USING ACUPUNCTURE TO TREAT CHEMOTHERAPY-INDUCED PERIPHERAL NEUROPATHY (CONT.) by Heidi Bartlett, L.Ac.

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

Acupuncture is an ancient medical The term de qi is recorded hun- has also been confirmed that with treatment that dates back close dreds of times in the Ling Shu, and electroacupuncture techniques, a to 2,500-3,000 years. It is one of it states how important it is that trained practitioner can target spe- the oldest, consistently practiced, the patient must feel a de qi sen- cific endogenous opioid receptors medical techniques in the world to sation in order for the treatment to for the release of specific endoge- date. To clearly understand those be effective. De qi is simply trans- nous opioid peptides.1 For example time frames I like to correlate lated as “big qi”, or more common- 2hz millicurrent has been shown 2,500 years ago, or about 500 BC, ly as a qi sensation. There are even to target the Mu receptor for the to more familiar historical events classical acupuncture de qi sensa- release of beta-endorphins. Just for clear reference. The birth of tions recorded over the millennium as 4hz targets the Delta receptor Jesus Christ stands out at around that are considered optimal for for enkephalin release, and 100hz 2018 years ago, the Roman empire patients to feel to achieve success targets the Kappa receptors for dy- was beginning to form as a con- with treatment, such as feelings of: norphin release in the spinal cord.1 cept, the Classical medical text the A skillful practitioner can apply this Huangdi NeiJing was just begin- Dull, achy neuroscience knowledge to their ning to be written, Ancient Egypt Fullness, distension clinical practice quite easily with was drastically changing to what Heaviness great effect. What is important is we understand of them today, and Hot that the practitioner understands the world’s view was that we were Cold why these effects occur, so adjust- the center of the universe with the Pin prick, slight pain ments can be made from treatment Sun traveling under the ground at to treatment for maximum clinical sunset through rivers of lava, and In my book, “Neuropuncture: A outcomes. arising in the morning on the other Clinical Handbook of Neuroscience side at sunrise. Acupuncture,” second edition, I Using neuroanatomy we can also clearly correlated each specific de examine how distal acupuncture Acupuncture’s rich ancient history qi sensation with the specific neu- points on the extremities can very is reflected in the medicine. The ral fiber that transmits that exact much effect visceral function. When stories of acupuncture’s power- sensation.1 Whenever our patients we investigate the neuroanatomy of ful healing have been told about feel that heavy de qi sensation, the spinal segments we find several curing the crippled and taking pain then it can only occur if the A-del- amazing facts. First, specifically away from the suffering. Continuing ta fibers have been stimulated by at the location of the dorsal horn today with reports of dramatically the needle, or more accurately of the spinal cord the somatic and reducing, and in many cases totally by the local chemical soup that visceral nerves converge into the alleviation of, severe and chronic is produced when needling, that one tract leading up to the brain, crippling nerve pain, to the walking stimulates the transmission of that the spinothamalic tract. This spinal of recent paralyzed patients, to the sensation to the brain. I look at this neural reflex is called the muscu- healing of tissues never thought as when my patient feels the de qi larvisceral reflex and there is also could be healed. All of these anec- sensation, then I have reached my a cutaneousvisceral (skin to organ) dotally stories do not fall short in target, the brain. We all remember reflex that explains Japanese style the area of miraculously fantastic, the multiple hand needle stimu- acupuncture. What this means is ‘mystical’, pre-scientific era, and lation techniques that are taught that when needling an acupunc- even totally unbelievable, but is to us to generate different de qi ture point, let’s use the traditional there any real science that explains sensations that are associated with acupuncture point Stomach 25, that how this powerful ancient art of specific treatment principles, such point is located on the T10 der- healing works, and equally import- as wagging the blue-green dragon’s matome, when stimulated the neu- ant, can we communicate that to tail, siphoning, rotation, twisting, ral transmission will enter the spi- our patients and other professional fire on the mountain, pounding, nal cord at the T10 level. So, what healthcare practitioners? scrapping, etc. Well, those hand visceral nerves also innervate at the techniques all produce a special level of T10? The stomach, spleen, Traditional Chinese medicine’s chemical soup locally that initiates pancreas, and the small intestine first classical medical text named the profound healing reaction that spinal nerves all have branches that the Huangdi NeiJing dates back occurs with acupuncture.1 innervate at T10. That means when to around 2,200-2,500 years ago. needling and stimulating St 25, you Most scholars of today will place This chemical soup has been an- will be also affecting those organs the composition around the late alyzed and confirmed to include and it isn’t surprising how St 25 is Warring States of Sun Tzu, 475-221 red blood cells, white blood cells, a great point for digestive condi- BC, through to the Han dynasty excitatory amino acids, prostaglan- tions, especially constipation. around 206-220 BC. This medical dins, histamine, NGF (nerve growth classic has two sections, namely the factor), and CGRP (calicitonin The second powerful neuroana- Su Wen and Ling Shu. The Ling Shu gene-related peptide).1 CCRP is tomical fact is that when a distal is the first medical text to describe one of the body’s strongest natural acupuncture point is stimulated and outline acupuncture techniques vasodilators, which locally encour- and the transmission innervates the and acupuncture treatment princi- ages more ‘pooling’ of that soup. spinal cord, at the level of the dor- ples, even listing acupuncture point We sometimes can see this during sal horn where that afferent trans- prescriptions for specific medical a treatment as the redness that mission innervates, three powerful conditions. This specific section circles the needle after insertion. neuropeptides are released.1 Those seems to be where, we, the West, This helps to explain how and why neurochemicals are serotonin, receive a lot of our fundamental local needling is so effective for noradrenalin, and enkephalin. All information about the mechanisms, conditions such as infections, in- three chemicals aid in down regu- and applications for acupuncture. flammation, and for treatments for lating ANY pain signals coming in It is in this text where we find the conditions such as plantar fasciitis, at that specific level, but also any important terms of de qi, mai, and and even tennis elbow. In the treat- transmission passing through that jing luo. ment of acute and chronic pain it level ascending up to the brain. We

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

may ask ourselves why, and how, is of the circulatory, and nervous Large Intestine 4, Hegu, such an in- system, centuries before the West, credible point for pain? Or why are and there is not one acupuncture some of the “extra” points in that phenomenon that I cannot explain area so wonderful at alleviating using neurophysiology. The term ANY pain in the body, even if it is meridian came from a French phy- sciatica? Well, when stimulating LI sician in 1908, which translated mai 4, you are directly stimulating the and jingluo as ‘meridian’ due to his branches of the superficial radial own personal energetic ideology. nerve. The radial nerve connects I have seen better translations as Dr. Michael Corradino, Doctor of to the brachial plexus and that simply pathway, or vessel. I urge Acupuncture and Oriental Medi- plexus innervates the spine at the you to replace the term ‘meridi- cine, and Founder/CEO of Neu- levels of C5-T1 (the radial nerve an’ with ‘pathway’ or ‘vessel’, the ropuncture LLC, graduated from is the upper branch and is associ- next time you read it in a Chinese Pacific College of Oriental Medi- ated with C5 innervation). When medical classic and see how that cine, Cum Laude, in 1995 with his that neurotransmission passes thru changes your point of view. Masters in Traditional Oriental the radial nerve, along the brachi- Medicine after studying molecular al plexus and then into the spinal Does reinvestigating acupuncture biology at Seton Hall University. cord at C5, those three powerful with neuroscience subtract any of Dr. Corradino is a published author neurochemicals are released and the powerful applications to acu- and international speaker in the will then down regulate ANY pain puncture? Does it degrade its long area of neuroscience and acupunc- signals passing thru that area of historical presence? Will applying ture, and he is currently involved in the spine ascending to the brain. If neuroanatomy to the TCM acu- groundbreaking research with elec- we understand this effect, it does puncture model take anything away tro-acupuncture and stem cell pro- not surprise us that LI 4, or any of from this powerful medical treat- liferation, spinal cord injury, opioid the extra points found locally, has ment? No, No, and NO!!! It only titration, and oncology. Currently a powerful effect on pain anywhere confirms what our Chinese medical Michael has a private practice in in the body. Another fun fact is that forefather’s were observing and San Diego, while developing and fMRI imaging has revealed that LI 4 illuminates the authenticity of our teaching Neuropuncture globally. has neural branches that terminate medicine, and galvanizes acupunc- in the hypothalamus and when stim- ture into the future of mainstream ulated it releases beta-endorphins medicine. It is practiced this way in that activate the PAG (periaqueduc- China, Korea, and many European tal gray), which is the pain station countries, and it seems like Amer- for the entire body.1 Wow, is that ican’s missed that subtle, yet pow- awesome or what? Now communi- erful, adjustment. I have devoted cate that in your next meeting with my professional career to learning any western healthcare practitioner and educating my colleagues in this and tell me you won’t have their exact area. I am currently involved attention! in ground breaking electroacupuncture research investigating spinal The TCM energetic model is sci- nerve regeneration, stem cell pro- entifically controversial, yet to be liferation, and much more. Please confirmed, and understood by many continue to educate yourself and to be historically mistranslated. Do raise the bar of standards for our we contain electrical energy? Yes. profession by being able to prop- Do we omit electromagnetic fields? erly communicate the how, and why Yes. Great white sharks have these our medicine works. anatomical structures named “am- pules of lorenzini,” that detects ex- REFERENCES actly this, the electromagnetic field of their prey. Our heart generates 1) Corradino M. Neuropuncture: A an electromagnetic field that ex- Clinical Handbook of Neuroscience pands about 3 meters in diameter Acupuncture. 2nd ed. Jessica King- every time our heart beats, and our sley Publishers; 2017. blood produces an electromagnetic field due to the iron it circulates2. 2) Becker RO. The Body Electric: Does this equate to what is com- Electromagnetism and the Founda- monly understood as ying qi, the tion of Life. 1st ed. New York, NY: qi that circulates in the ‘pathways’ William Morrow & Co., Inc; 1985. in TCM? I do believe so but not in a mystical, non-scientific realm. In the Ling Shu, it clearly states many times that some of these pathways can be seen with the naked eye under the skin, and that they all once originated from the heart and that they contain the blood and nutrients absorbed by the digestion and then circulated throughout the body for health. If you ask me, I believe that the Chinese ancient physicians had an astute understanding

16 MOXIBUSTION THERAPY IN THE TREATMENT OF RADIATION FIBROSIS OF THE THROAT Dr. Bianca Di Giulio, DAOM, L.Ac. | Dr. James Munson, DAOM, L.Ac.

ABSTRACT specific areas of the throat pro- cancer develops.2 Major risk factors vided significant improvement and for this type of cancer include Head and neck cancers are less results. In combination with local excessive alcohol consumption and common than other neoplastic electro-acupuncture and pricking smoking. Acute physical symptoms disease, accounting for approxi- therapy, positive outcomes were of disease may begin with chronic mately 3% of cancers in the United achieved after only three treat- sore throat, dysphagia and inability States.1 The following case study ments. A significant decrease in the to swallow solid foods, ear pain, or demonstrates the clinical benefits fibrotic tissue of the affected area awareness of a lump in the throat of moxibustion therapy, a modality was measured at each follow-up and changes in voice, like hoarse- within the practice of traditional visit indicating positive results. ness.2 Chinese medicine (TCM), for radiation fibrosis of the throat. This UNDERSTANDING DIAGNOSIS The Western medical diagnosis is condition was caused by extensive AND TREATMENT FROM A achieved through various tests to radiation therapy in the treatment WESTERN MEDICAL PERSPECTIVE: determine exact stage and loca- of stage II laryngeal cancer in a fif- LARYNGEAL CANCER tion of cancer. After a complete ty-nine year-old male patient. The health history and physical exam, side effects of radiation therapy led Laryngeal cancer is a type of head the patient may be referred for a to chronic swelling and hardening and neck cancer. Malignant cells chest x-ray or Barium swallow, also of the tissue affecting the trachea are identified in the soft tissue of referred to as an upper gastrointes- and vocal chords, which required the larynx, a part of the throat that tinal series.2 This test requires the a semi-permanent tracheostomy resides at the base of the tongue patient drink a liquid with barium tube. Radiation oncologists esti- and trachea. The anatomical struc- to coat the esophagus and stomach mated the tube would remain for ture of the larynx includes three before x-rays are taken. Abnormali- approximately 2-4 years. parts. First, the supraglottis, the ties can also be discovered through aspect above the vocal chords, the laryngoscopy, in which a thin tube- At the time of the initial visit, second is the glottis, where the like structure is inserted into the the tube had been in place for vocal chords are located, and third larynx to view and remove tissue ten months. The patient sought is the subglottis that sits between samples. If this occurs the tissue Chinese medicine treatments to the vocal chords and the trachea is taken to pathology to screen alleviate the physical discomfort (windpipe). The larynx is respon- for cancer. Other imaging may be caused by fibrosis, including local- sible for the voice by way of the required like computed tomogra- ized pain, difficulty swallowing and vocal chords that vibrate when air phy (CT scan), positron emission speaking. The dispersion method is directed at them. Squamous cells tomography (PET scan), and bone of direct moxibustion therapy on line the inside of the larynx where scan.2 MOXIBUSTION THERAPY IN THE TREATMENT OF RADIATION FIBROSIS OF THE THROAT (CONT.) Dr. Bianca Di Giulio, DAOM, L.Ac. | Dr. James Munson, DAOM, L.Ac.

size and lack of spread did not his neck, which, at the time of the The standard of care in convention- require surgery or chemotherapy, initial treatment, was adjusted to al medicine for laryngeal cancer standard protocol was six weeks of its largest circumference. include the following: surgery, daily radiation therapy. Within two chemotherapy, and radiation ther- weeks of completing the course of He continued to explain that the apy. The method and course of treatment, he reported difficulty previous year had clearly affected treatment is dependent on multiple breathing and experienced acute his physical and emotional health. factors like degree of spread, type, respiratory distress. He was rushed His energy and stamina was report- stage and health of the individu- to the emergency room where a tra- ed as very low, he required sleep al. External beam radiation ther- cheostomy was performed. This is a medications to fall and stay asleep, apy (EBRT) is a common method surgical procedure wherein a hole and maintained a long history of of treating many types of cancer, is made from a specific point on insomnia. His body tended toward including those of the head and the neck into the trachea to allow hot, with desire for cold drinks, and neck.2 EBRT functions by creating oxygen-rich air to reach the lungs. a constant dry mouth. Prior to his small beams of electromagnetic cancer diagnosis, he was treated waves (radiation) that permeate the In this particular case, the tra- for asthma, which required the tissue in precise locations to erad- cheostomy became a permanent use of inhalers during activity. His icate cellular disease. Prolonged outcome due to excessive radia- blood pressure was elevated requir- radiation therapy can cause a host tion therapy causing fibrosis of the ing prescriptions. He experienced of side effects, from superficial er- throat. The hardening of the tissue occasional headaches and reported ythema of the skin, and local sensi- impacts the open passageway of digestion as normal. Prescription tivity, to deeper and more progres- the trachea, becoming immobile, medication included Vicodin (as sive clinical symptoms in the fibers firm, and compromising the simple needed), Prozac, Lisinopril, and of muscle and soft tissue.1 act of respiration. Not only does Xanax. this affect the ability to breathe, The effects of radiation can re- but eating and swallowing with RFS CHINESE MEDICINE DIAGNOSIS sult in a condition referred to as is also compromised. Consequently, radiation fibrosis syndrome (RFS). the patient remained in the hospi- The current academic literature The tissue in the surrounding area tal for three weeks with a feeding for Chinese medicine practitioners becomes fibrotic, hardening into tube and underwent rehabilitative seeking guidance for cancer pa- a firm mass, which in the case of therapy with vocal cord specialists, tients is limited. Due to the very head and neck cancers, can impact speech therapists, dieticians, and nature of cancer being a resilient- the vocal chords, esophagus, and physical therapy. ly complex disease, the available ability to eat, speak and breathe material is not exhaustive of every normally.3 Once this occurs there This patient was referred to our cancer, stage, diagnosis and treat- are very limited treatment options. Chinese medicine clinic approx- ment. Therefore, clinicians must Physical therapy and speech reha- imately eleven months after the diligently research and hone their bilitation is necessary in most cases Western medical procedures. A clinical skills to treat patients with and are methods that are familiar thorough intake indicated the RFS lesser-known or more rare tumors. to and approved by radiation on- impacted activities of daily living Nasopharyngeal cancers exist cologists. Massage, heat therapy or and overall wellbeing. Three-month within that category. Fortunately, myofascial release is cautioned due follow-ups with his oncologist con- TCM physicians can rely upon pat- to the conventional understanding firmed he was cancer free. Despite tern differentiation, including the that local manipulation or heat being cleared of malignancy, the eight-principles, interior-exterior, application would lead to internal patient expressed immense frustra- and excess-deficiency to properly irritation and inflammation. tion with the tracheostomy tube. diagnose and effectively treat. According to the patient, “the doc- Examination of the patient’s tongue CASE STUDY: MOXIBUSTION tors and therapists have nothing and pulse demonstrated a mixed THERAPY FOR RADIATION FIBRO- else to offer. They say I just have syndrome. This is often true with SIS SYNDROME to wait it out and hope the fibrosis individuals diagnosed with cancer decreases.” and complex disease patterns. The A fifty-nine year-old male present- tongue body was red with deep ed with acute radiation fibrosis of With ease, he used his tracheos- cracks in the middle and upper the throat due to EBRT he complet- tomy tube to describe his symp- jiaos, and a greasy-yellow coat in ed nine months prior, for stage II toms. Stating that internally his the rear. The pulse furthered this laryngeal cancer. The patient re- throat felt extremely dense. He was pattern, the Liver was wiry-full, ported that he first noticed discom- acutely aware of an immobile mass Spleen slippery, Kidneys deep, thin, fort in his throat with mild difficulty that never decreased in size. He and the overall rate was rapid. swallowing and intermittent ear- gestured to his throat and pressed aches. Due to the slow progression firmly along the sides of the throat, TCM diagnosis: of symptoms he postponed seeking across the scalenes, bilaterally. As medical treatment, expecting the he pushed, he said it was “hard Upper jiao phlegm with toxic heat, discomfort to resolve. The patient as a rock.” There was no report qi-blood stagnation, Kidney-Liver has a history of alcoholism and of pain, but he explained that he yin deficient heat long-term tobacco use, which lead could feel tenderness and swell- him to ignore the symptoms and ing inside the throat locally. The TCM treatment principle: dismiss them as acute side effects extensive swollen area extended of his addictions. The dysphagia ul- from just above the laryngeal prom- Dissolve phlegm, clear toxic heat, timately worsened to an extent that inence, to the jugular notch and clear deficient heat, nourish yin he sought medical care with his approximately four inches lateral in and calm spirit. primary physician. He was referred both directions. for endoscopy with barium swallow Effective Application of Moxibus- to image the throat. Under general Palpation by both practitioners tion Therapy for Radiation Fibrosis anesthesia, tissue was removed, exhibited hardened, fibrotic tissue, Syndrome: biopsied and stage II cancer was warm to the touch, swollen, and confirmed. visibly red. Applying pressure did Moxibustion therapy was instru- not elicit pain. He explained there mental in the patient’s reduction This stage and pathology indi- was a constant need to clear his of symptoms as a result of RFS. cates a tumor that has not grown throat, with a mild, chronic cough Therefore, we have outlined its outside of the throat. There is no because of phlegm and sputum that application as a singular, useful lymph involvement, nor spread would not flush naturally through modality for practitioners. Theoret- to distant sites. Since the tumor his throat. He wore an ascot around ically, moxibustion may seem coun-

18 terintuitive in this case given that the integrity of the skin, sensory Results heat therapy is generally consid- function, and normal sensation has ered a contraindication with signs been greatly compromised due to Immediately following this treat- of heat, like redness or swelling. radiation therapy. By and large, ment, palpation on the throat and There is a concern its effects will Western-trained doctors believe neck demonstrated soft, more mal- inflame or worsen the condition. heat is contraindicated with signs leable tissue that shifted slightly This is especially true with respect of swelling and redness, and as a with pressure. When the patient to philosophy and clinical applica- result, caution patients to receive was asked to swallow, he reported tion in Western medical paradigms. any kind of physical or manual that the mass of rigid, fibrotic tis- However, TCM relies upon the therapy because of the higher level sue that enveloped his throat had treatment philosophy of “like treats of sensitivity. Thus, the practi- lessened, allowing more movement like,” proven in this case study with tioner needs to judge appropriate when he swallowed. The yellow proper technique of moxibustion strength of treatment through their coat on the tongue dispersed, his therapy. own skill and observation without pulses slowed to a normal rate, and relying on the patient’s feedback as visually, the systemic redness and Safe method and application of they may not feel the heat acutely. inflammation that was present on moxibustion for this case is high- his cheeks, forehead, and overall lighted below: Constitutional Support: skin tone, lessened. Acupuncture Therapy Type: coarse, green, low-grade Treatment #2 moxibustion was utilized to create Moxibustion was an integral com- an intense, strong dispersing heat ponent to alleviate discomfort The patient returned two weeks Size: moxa was shaped into very and hasten healing of the fibrotic later and reported he was able to tight, firm cones in order to create tissue. Given that Chinese medicine decrease the length of his ascot a slow, intense heat (approximately is a synergistic system that incorpo- size down to a smaller clasp. He the size of a Hershey’s Kiss) rates multiple modalities for heal- was very encouraged by this quick Quantity: 4-6 cones were placed ing, constitutional acupuncture was response. Palpation indicated directly on the patient’s throat at also employed. The following acu- smaller mass circumference and the specific areas with most fibrotic, puncture point combinations were edges of the fibrotic area were less tight, dense tissue included as part of this patient’s rigid. He noted improvement in his Method: Using an incense stick, sessions. In total, he received only ability to swallow solid food and a each cone was lit and watched three treatments, but substantial decrease in the tendency to clear carefully as it burned toward the changes were evident following his throat from rattling phlegm. He skin. The cone was removed when each visit reported by the patient reported that he did not need to the patient reported a sensation of and observed by the practitioners take Vicodin during this two-week heat directly under the cone, or the through palpation. period for throat pain. However, practitioner estimated that enough the patient disclosed a long history heat had accumulated locally Treatment #1 of alcoholism and stated he was Technique: The cone was removed beginning to attend sobriety meet- with forceps and placed in a cup of Tongue: Red, deep cracks, sticky ings. Given that alcohol is a prima- water. The point was not covered yellow coat ry risk factor to laryngeal cancer, by the finger to retain heat, but Pulse: wiry, chi positions deep, the cellular pathology is rooted in rather to allow the heat to disperse Lung/Heart excess, slippery, this condition, but also illustrates internally slightly rapid deeper emotional roots and com- Duration: This technique was re- plex patterns that correlate to his peated on each point until there Acupuncture: overall well-being and health. were palpatory and/or visual changes, or the practitioner deemed it Seirin needles used for all The subsequent treatment plan adequate for treatment acupuncture included moxibustion, auricular acupuncture to support alcohol The larger, tightly packed moxi- Open Ren: LU 7, K 6 withdrawal, and an eight extraor- bustion cone causes a longer burn - Pathway of the Ren channel dinary meridian (EEM) protocol time, which allows more heat to courses through the throat utilizing the Dai meridian to dredge develop and facilitate the scatter- - Combination of extraordinary and open the Liver and Gallblad- ing of the heat toxin as well as to meridians nourishes yin der, clear heat, detoxify the system, encourage wei qi (defensive qi) to Open Chong: SP 4, PC 6 and move and regulate qi. The Dai the surface and aid in the disper- Ren 6, Ren 12, Ren 14, Ren 22 treatment is indicated for emo- sion. In TCM theory, not imme- - Palpation along the Ren tional release and letting go - also diately covering the point upon meridian exhibited skin changes therapeutically relevant for this removing the cone, allows the heat/ in tone, texture, and temperature patient. evil pathogen to exit. However, it is on the above noted points, which crucial that the practitioner quickly were then needled in dispersing Tongue: red, deep cracks, sticky place the next cone in the same method yellow coat location, if necessary, to keep the LV 14 Pulse: wiry, Kidney deep-thin, heat at a steady, high level. - Spread Liver qi Lung/Heart slippery, slightly rapid ST 40 In this case, palpation and close - Clear Phlegm Acupuncture: visual examination was integral SP 9 to deciding how many cones were - Clear Damp Auricular (bilateral): Shen Men, Liv- applied to each point. When the Local: 2 ashi points on each side of er, Lung 1, Sympathetic, Kidney tissue softened and there was less the throat, approximately on Large Local (ashi throat, bilateral): needle density with pressure, this indi- Intestine channel angled medially toward the mass, cated positive change and heat inserted approximately ½ cun reduction. In addition, with close Moxibustion: - Electrical stimulation (e-stim) examination,g the area became less leads were placed on four of the swollen and red. It is important to Dispersing technique, direct cones throat needles, 10 hz, increased state that this type of technique placed in 4 positions on throat and slowly to a level where the patient needs to be done with the full each applied three times. Please reported a noticeable, continuous understanding and consent of the see above section for discussion frequency patient, and by those practitioners and technique. - Needles retained for twenty who are experienced and confident minutes with moxibustion. In a case of RFS,

19 MOXIBUSTION THERAPY IN THE TREATMENT OF RADIATION FIBROSIS OF THE THROAT (CONT.) Dr. Bianca Di Giulio, DAOM, L.Ac. | Dr. James Munson, DAOM, L.Ac.

Open Dai: GB 41 (left first), LV 13, the throat, culminating on the 3rd GB 26, GB 28, Ren 15 toe at ST 45 Topical: Moxibustion: Zhen Gu Shui was applied topical- Indirect, dispersion technique ly at the end of the session to the along the throat combined with throat four rounds of direct cones on two local areas where thicker fibrotic Moxibustion: tissue remained. Bianca Di Giulio is a Doctor of Acu- Indirect heat applied with smoky Results puncture & Oriental Medicine and moxa over areas of significant hard- has been in practice for over ten ness using the dispersing method. After the third treatment the The moxa stick is held over the patient called to report positive years with a specialty in Chinese identified point, with the practi- changes in the mass and associated medicine oncology, supporting the tioner’s hand placed between the symptoms, but decided to return cancer patient toward health and heat and the skin to moderate tem- to a rehabilitation center to ad- healing. perature. The moxa is held until the dress his alcoholism. Although the heat escalates and then the stick is course of treatment was quite short pulled away for a moment, before and not the preferred duration returning to the same position. The to properly address his concerns, point is not covered with the sup- both practitioners were optimistic porting hand in order to disperse that with ongoing treatments the the heat. fibrotic tissue would slowly continue to soften and symptoms would Treatment #3 improve as a result.

The patient returned to the clinic CONCLUSION one week following the second session. The circumference of the mass This case study illustrates the had decreased in size significantly, range of traditional Chinese medi- which was confirmed by the patient cine techniques in the treatment of James Munson is a Doctor of noting the ascot size was now at cancer-related conditions, like RFS. Acupuncture & Oriental Medicine its tightest possible placement. He The side effect of radiation thera- dedicated to improving his pa- reported that internally his throat py can extend from the superficial tient’s health and preventing illness felt less inflamed, large, and swol- erythema, to deeper levels of soft utilizing the system of traditional len and had “opened up.” There tissue changes requiring specific Chinese medicine. was also an evident shift in his and refined approaches. Although emotional state, observable from the practitioners were only afford- both the practitioner’s perspective, ed three treatments to address but also shared by the patient, and a well-established condition, the independently confirmed by his clinical outcome was evident. It is daughter. He was making decisions also important to note that with to return to rehab for his alcohol- just a few moxibustion cones and ism, and expressed more optimism needles, immediate results were at- about his health and the future. tained. This speaks to the synergistic aspect of TCM modalities and Tongue: Red, deep cracks, thin- how treatments need not be overly yellow coat involved, especially when appropri- Pulse: wiry, rapid; Lung/Heart ate modalities are used together thin-slippery as they were intended in classical Chinese medicine. Acupuncture: REFERENCES LI 4, LV 3 - Classic “4 Gates” point combina 1) American Society of Clinical On- tion to circulate qi-blood, move cology: Head and Neck Cancer Sta- the Liver, tonify qi tistics 2017. Alexandria, Va. https:// ST 40, SP 9 www.cancer.net/cancer-types/ - Resolve Damp and Phlegm Accu head-and-neck-cancer/statistics. mulation Accessed March 27, 2018. Ren 17, Ren 22 - Open the chest and throat, de 2) National Institute of Health- Na- scend rebellious qi tional Cancer Society. Laryngeal ST 25, Ren 12, Ren 6 Cancer Treatment (Adult). https:// - Classic “4 Doors” point www.cancer.gov/types/head-and- combination to regulate diges neck/hp/adult/laryngeal-treat- tion, by nourishing Spleen-Stom ment-pdq. Accessed March 15, ach qi, tonify and raise qi 2018. Local (ashi points, bilateral): approximately six acupoints along the 3) Hojan, K., & Milecki, P. (2014). lateral aspect of the mass, accord- Opportunities for rehabilitation ing to palpation of patients with radiation fibro- - Electro stimulation attached on sis syndrome. Reports of Practical all six point locations, beginning Oncology and Radiotherapy, 19(1), with 10 Hz 1–6. http://doi.org/10.1016/j. Pricking therapy (bilaterally): ST rpor.2013.07.007. 45, in-out needling method to clear heat - The Stomach channel descends from the orbital region, through

AN INTERDISCIPLINARY PERSPECTIVE ON THE OPIOID CRISIS by Elena Roemer, DACM Candidate

“Presently she cast a drug into the ETHNOBOTANICAL HISTORY BASIC NEUROSCIENCE wine of which they drank to lull all OF OPIOIDS pain and anger and bring forgetful- Humans’ relationship with opioids ness of every sorrow.”1 The inebri- spans millennia. To understand To understand why this medicine is ant described in Homer’s “Odys- the issue in the broader scope of so powerfully effective, it is helpful sey” depicts the equivalent drug history, it’s worthwhile to look at to understand its basic mechanism experience currently overwhelming the relationship humans have had in the brain. Endorphins (short the United States: opioids. This with this drug over time. Opioid for endogenous morphine) are a class of drug has taken many forms drugs may be derived from the class of neurotransmitters naturally throughout history, from opium to opium poppy (Papaver somniferum) produced by the body that elicit fentanyl and has played a major as either natural drug isolates like pleasure and are involved in pain role in influencing civilization. This morphine or semi-synthetic com- mediation. Endorphins are structur- is by virtue of the neurobiological pounds like oxycodone; or they ally related to exogenous opioids, affinity humans have for it’s euphor- may be fully synthetic like fentan- and both work at the same recep- ic and pain-reducing effects. The yl. Opium poppy cultivation dates tor sites in the central nervous over reliance on opioids as tools back to 3400 B.C.E., in the first system.17 These receptors are like has lead to millions in the clutches known human civilization of Meso- a lock that fits the keys of both of addiction and an current esti- potamia.8 It was then passed down the endogenous (endorphins: Beta mated average of 115 people a to major ancient civilization, in- endorphin and enkelphins) and day dying of accidental overdose cluding the Egyptians, Babylonians, exogenous opioids (oxycodone and in the United States.2,3 From an and Chinese.9 Opium was intro- heroin). However, the pharmacolog- epidemiological perspective, the duced to modern Western medicine ical profile of the exogenous opi- current problems associated with in the 16th century in the form of ates are stronger and consequently opiate abuse are not affecting all laudanum, an alcohol extract of the they have severe side effects.17 demographics equally. Consequent- poppy by Swiss doctor and alche- ly the current political approach mist, Paracelsus.10 Morphine, one of The side effects of these exog- being taken has a different rhetoric its active alkaloid constituents was enous opiates have been noted compared to other drug epidem- first isolated in 1805 in Germany throughout history. According ics, like that of the crack-cocaine and has been used by physicians to ethnobotanist MJ Brownstein, epidemic of the 1980’s.4 Neverthe- ever since.11 Shortly after, the Unit- “Starting in the 16th century, less, with President Trump’s dec- ed Kingdom went to war with China manuscripts can be found describ- laration of this as a public health over the trade of the poppy in the ing drug abuse and tolerance [to emergency and more recent grim first of two Opium Wars from 1839- opium] in Turkey, Egypt, Germany, threats for traffickers,5 legislators, 1842.12 Around this time, thousands and England.”15 Tolerance is the community leaders, and health care of pounds of opium were annually crux of the current crisis, as one providers are looking for answers. imported into the United States of the expected side effects of It is imperative to look at failings and the famed “Opium Dens” of taking medications like Vicodin and of past drug crises as solutions San Francisco were prevalent. In OxyContin. With repeated use, the are formulated. Revised tools for 1973, the Drug Enforcement Agency pain relieving effects of opioids pain and addiction are needed to (DEA) was created by President are diminished due in part to a help the thousands desperate for Nixon to address the growing decreased sensitivity at the recep- help, many of which are offered by rise of heroin use.9 In present tor site, and users increase the integrative medicine. Traditional day, the United Nations reported dose in order to get results.18 This Chinese Medicine and other modal- the production of opium poppies escalates the risks of dependence, ities of integrative medicine offer in Afghanistan reached a record addiction, and adverse effects like many tools for pain management high in 2017, causing alarm for its constipation, nausea, and respira- and addiction treatment. In order implications on the ongoing wars tory depression.19 for these modalities to be success- and global drug trade.13 Meanwhile, ful in decreasing opioid use and in the United States, pharmaceu- Abuse of an opioid often begins dependence, they must be embed- tical companies who produce and when an individual experiences ded in larger public health efforts distribute opioid medications, like the sense of euphoria brought and aligned with key public health McKesson, are some of the most on by the drug and then tries try principles: prevention, equitable profitable in the world, reporting re-create these feelings. This may access, and compassion. $198.5 billion revenue in 2017.14 be done with techniques like nasal inhalation, injection, or increasing According to the Center for Dis- This timeline illustrates Papaver the dosage.20 Opioid abuse also ease Control, one out of every somniferum’s far-reaching impact changes the level of dopamine in five people diagnosed with a pain on history. The value and signifi- the brain, associated with feelings disorder is prescribed opioids.2 An cance this plant has played cultur- of excitement, and provides pos- estimated 2.1 million people suf- ally is hard to fathom. Anthropol- itive reinforcement for continued fered from substance abuse relat- ogist, P.G. Kritikos, described how abuse.17 Long-term opioid use caused to opioids in 2012.2 According the poppy was used in religious es the brain to produce less of the to the Kaiser Family Foundation, ritual by the ancient Greeks as a various neurotransmitters, includ- the number of accidental opioid euphoriant.15 16 By the Sumerians, ing dopamine, serotonin, GABA, overdoses doubled in five years it was known as “hul gil” or joy and endorphins due to the over- between 2011 to 2016.6 The Ameri- plant.15 Meanwhile, it was valued whelming surge caused by using can Society of Addiction Medicine as a medicine all over the world the drug.17 18 When the brain stops cites drug related overdoses as the as it traveled along the Silk Road. producing its own neurotransmit- leading cause of accidental death Though different cultures may have ters to feel good, the user feels in the United States, surpassing car had distinct medical applications, more drawn to continue using opi- accidents. Furthermore, four out of it is clear P. somniferum’s most oids. As these biological processes five heroin users start with the mis- compelling effects are on shifting occur and levels of dependence use of prescription painkillers.7 consciousness and alleviating pain. become severe, users become des-

22 perate to maintain this new level of are simply out of reach. For exam- puncturists have a large toolbox for baseline. Also seen in this current ple, the average cost of an inpa- managing pain with acupuncture crisis is when access to prescrip- tient privately run rehab program and herbs. Acupuncture analgesia tion opioids becomes unavailable, can range between $6000-$20,000 a is supported by many randomized people struggling with addiction month.30 The Affordable Care Act of controlled trials on both on humans will turn to the relatively inexpen- 2010 requires insurance providers as well as animals: one of the well sive and readily available alterna- to cover addiction services, though researched theories on it’s mecha- tive heroin.7, 13 According to the very few treatment centers actu- nisms of action is by working on the CDC, the rate of heroin overdoses ally accept this type of insurance, endorphin system. 34, 35, 36, 37, 38 Along increased five fold between 2010 to including Medicaid.31 Alternative with the growing body of evidence, 2016.21 Those being sold heroin are treatment centers are available. For acupuncture has thousands of years often given a concoction of differ- example, the Salvation Army offers of empirical practice showing its ent opioids, sometimes containing services for those with low to no safety, efficacy, and minimal side the highly potent synthetic opiate income or insurance, yet these are effects. Fentanyl, which has led to stagger- state-funded or non-profit entities ing overdose rates.22 relying on donations or government In addition to acupuncture, there allocated resources. are many herbal medicine therapies EASY ACCESS from both Eastern and Western The primary medical treatment for traditions that can be implement- Until recently, opioids have been a opioid addiction is Methadone ed for managing pain. Yan Hu Suo primary treatment for a wide variety and Buprenorphine, drugs that act (Corydalis chinesis) and California of pain disorders by biomedical as a replacement for prescription poppy (Eschscholzia californica) are health care providers. In response opioids or heroin. Methadone, a both herbs in the Papveracea fam- to the current crisis, the CDC is- full opioid receptor agonist, is the ily, the same as the Opium poppy, sued new guidelines for safer prac- gold standard for treating addic- that act at the same opioid recep- tices in prescribing these medication, however this substance is also tor sites to reduce pain.39 Curcum- tions in order to curb problematic a highly addictive substance and in, an active compound in Turmeric, over-prescription by doctors.23 Be- it’s use is stigmatized.32 Buprenor- has recently gained major popular- tween 1998 and 2010, the amount phine on the other hand, is only a ity in the West for pain and inflam- of opioids dispensed by pharmacies partial opioid receptor agonist and mation. In a systematic review when in the U.S. doubled.24 In 2013, there therefore does not have the same Curcumin was put in a head to head were enough prescriptions written euphoric effects of methadone. against NSAIDS (Ibuprofen,) the re- for every American to have their However, Buprenorphine is not as sults found similar significant pain own bottle of pills.2 Some states readily accessible as Methadone.33 reduction over the 4-6 weeks of the have more painkiller prescriptions Other medical treatment options study’s duration.40 There are several than there are people living in that like Naltrexone and Vivitrol, opioid classic Chinese herbal formulas like state.2 25 Nonetheless, over 75% of antagonists that prevent effects of Shen Tong Zhu Yu Tang and Shao people abusing opioid painkillers opiates, have not been shown to Yao Gan Cao Tang, which are tra- are not getting it directly from their be effective when compared to pla- ditionally used to move the blood, doctors, but from either a friend, cebo.33 Psycho-social interventions have been shown in to be effective relative, drug dealer, or off the in- like working with a psychotherapist, for decreasing pain.41,42 The latter ternet. 25 Though the problem may joining a peer support group like formula contains Bai Shao (Paeonia originate in the doctor’s office, the Narcotics Anonymous, and having lactiflora,) high in anti-inflammato- pleasurable and addictive nature of supportive social network also play ry, pain modulating polyphenols,43 this substance lends itself to prolif- a critical role in treatment,.33 and Gan Cao (Glycyrrhizia glabra) erate out into communities. which contains pre-cursors to corti- INTEGRATIVE MEDICINE costeroids that have anti-inflamma- In 2015, while law enforcement SOLUTIONS tory effects44. Even cannabis (Can- efforts continued on street drugs, nabis sativa) though perhaps laden legislators eased regulations on The medical community contin- with it’s own potential for abuse, incoming opioids from the pharma- ues looking for solutions for this may be a helpful harm reduction ceutical industry under the pressure crisis both downstream for treat- tool for mediating chronic pain.45 of highly affluent lobbyists.26 The ing patients addicted opioids There is also interesting research law is called the “Ensuring Patient and upstream in helping patients suggesting the co-administration Access and Effective Drug Enforce- manage pain. With the new stricter of cannabis with opioids is safe and ment Act”27 and effectively weakens CDC opioid prescribing guide- increases analgesic effects, and DEA restrictions on the top com- lines, providers have fewer options may allow prescribers to decrease panies who produce and distrib- to support their patients. Thus opioid dosing.46 Additionally, in ute opioids like Cardinal Health, integrative medicine may play an states where medical cannabis is le- McKesson, and AmerisourceBergen. integral role in providing alter- galized compared to states without This along with the surplus of Mexi- native approaches to treatment these laws showed a reduction in can and Afghan produced heroin,13 and pain management. Chinese opioid overdose mortality by 24.8% resulted in an explosion in avail- philosophy’s classic axiom on pain that increased over time.47 ability of opioids in the country.28, 29 states: “If there is free flow, there is no pain; if there is no free flow, Additionally, integrative medicine AVAILABLE TREATMENT OPTIONS there is pain.” Traditional Chi- has many tools to offer patients nese Medicine (TCM) has a broad withdrawing and trying to overcome The U.S. now finds itself with the lexicon for describing the origins struggles with addition. Acupunc- major question of how to address of pain; for example it can be due ture is a great modality for support- the thousands of newfound ad- to: blood stasis, qi stagnation, cold ing opioid detoxification and re- dicts. While there are programs in congealing, heat, and Bi syndrome. ducing cravings, particularly using existence for many suffering for With this breadth of etiology and the auricular National Acupuncture addiction, some treatment options sophisticated diagnostic lens, acu- Detoxication Association (NADA)

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

protocol.48 Acupuncture and herbs, Though this prejudice may be hav- place.2 However, President Trump including Chinese formulas, can be ing a protective effect for POC, this did mention of some public health helpful for managing the side ef- may also mean they are getting less measures: like access to rehabili- fects of withdrawal: insomnia, body than adequate treatment for their tation programs, funding research aches, diarrhea, muscle spasms, pain. for non-addictive pain medication, and nausea.49 Many herbs used to requiring more training for pre- support the nervous system, or Being that the opioid crisis is scribers of these medications, and “Spirit” as is described in TCM, primarily affecting white Ameri- increasing availability and com- also play a vital role in supporting cans, the political language used munity trainings for Naloxone, a the emotional aspect often integral to describe the problem shifts, as harm reduction medication used to in addition and recovery.50 well as how to deal with the drug reverse overdose. While there has users. Since the advent of the gov- been skepticism on if these prom- HEALTH INEQUITIES IN THE OPI- ernment-led “War on Drugs” in the ises can take effect64, the adminis- OID CRISIS 1970’s, the use or abuse of specific tration’s two-year budget proposes drugs has been seen as a criminal to allocate a substantial amount of Integrative medicine, acupunc- justice issue, implementing harsh resources into research, prevention, ture in particular, finds itself in an sentences such as the three strikes and treatment services. However, it influential position in this crisis, policy and mandatory minimum also aims to cut government fund- as it is able to treat both pain and sentences for illegal drugs. This ed health insurance programs like the complications of addiction. As approach not only fell short of its Medicare and Medicaid, leaving these modalities continue gaining promise to reduce drug use, it also many without coverage.65 popularity and recognition, the resulted in severe racial injustice hope is that access also continues in our prisons. Men of color are dis- The Trump administration has also to expand. This is essential as the proportionately targeted by police made it very clear that they are burden of the crisis falls on those for drug crimes, at a rate of five to taking a strong punitive criminal who have the least availability of one.57 Furthermore, even though justice approach to the crisis. In alternative options.51 This is where the current numbers show a dispro- President Trump’s more recent policy could play a critical role: en- portionate number of white abus- speech regarding the crisis, he suring these treatments are acces- ers in this opioid crisis, there are declared that those prosecuted sible for anyone on the socio-eco- still more POC being charged with trafficking opioids are deserving nomic scale and that barriers to opioid and heroin related offens- of capital punishment and praised entry are removed. Several surveys es.58 However, with the white face President Rodrigo Duterte of the have shown that aside from Asian of the current drug crisis, the view Philippines for having taken a communities, minority patients of drug user shifts from criminal similar approach66 This is radical- and those of lower socioeconomic requiring punishment to patient ly different from moving towards status are not as likely to use acu- needing rehabilitation. Legislators a public health approach. This puncture.52 A disparity exists across are hit hard to find treatment for is especially true with Attorney all health services for minority the people struggling with addic- General Jeff Sessions at the helm patients53, and especially for pain tion in their districts, as hundreds of the Department of Justice, who management. The disparity in the die monthly; most of whom look has a history of racially hostile case of acupuncture use is often like them.59 However, the numbers comments and voting record67, as due to cost52. However, one study of this current crisis could be com- well as recently reinstating longer looking at use rates by minority ad- pared to those of the crack cocaine sentences for drug prosecutions.68 olescents at free acupuncture clinic crisis of the 1980’s and 90’s60, af- As history has shown57, unless sig- in an urban hospital setting showed fecting mostly urban black commu- nificant changes are made within that when this barrier is removed, nities; though the approach of this the nation’s criminal justice system, diverse communities are more likely era was not one of compassion. 4 this punitive approach will likely to use acupuncture.52 This is again mirrored in the heroin not solve the problem but continue crisis of the 1970’s, “with a punitive to result in disproportionally more Interestingly, the current opioid approach to black heroin users co- POC incarcerated. crisis is not equally divided along inciding with a great expansion of racial lines: it is primarily a prob- methadone maintenance programs A radical public health resolution is lem for White Americans. In 2015, — for mainly white “patients.”61 decriminalization. Both the World according to the Kaiser Family These racial double standards Health Organization69 and United Foundation, of the 33,091 people result in health inequities, from Nations70 have advocated for this who died of an opioid related over- the doctor’s office, to how law is approach. This follows the major dose, 27,056 were White, non-His- enforced, to how people with drug successes of Portugal’s decriminal- panic.6 This means less than 20% addiction are treated. ization and public health campaign of the total overdose deaths are of 2001, decriminalizing drug use people of color (POC). Interpreta- POLITICAL APPROACHES and expanded its public health tions of this data have pointed the efforts to more compassionately cause to be from racial and ethnic With President Trump’s announce- help addicts. The Health Ministry disparities in pain management53. ment in October 2017 of the of Portugal estimates that 25,000 POC are less likely to receive epidemic being a national public Portuguese currently use heroin, opioid prescriptions than non-his- health emergency,62 there was a down from 100,000; and the opioid panic white patients for a variety of familiar Reagan era moralistic tone: overdose rate has decreased 85% pain conditions.54 This differential responsible citizens should abstain since the policy began.71 While behavior by prescribers is linked to from the evils of drugs under all drug dealers continue to be sen- inherent biases and stereotyping circumstances and “Just Say No.” tenced to prison, when someone is minority patients55; for example Like the Nancy Reagan campaign of found with a personal possession being concerned pain complaints 1980’s, this not only is ineffective63 of drugs, they are instead sent to are merely for seeking drugs or that but it undermines how and why a meeting with social workers who POC patients may sell their pills.56 people are using opioids in the first provide resources for addiction and

24 mental health support. Another programs and private companies. important part of the public health Insurance coverage compels pa- campaign is the government-fund- tients to use these services when ed outreach vans, which make out-of-pocket expenses are min- rounds on the streets of Portugal imized. Advocates and lobbyists giving out free methadone to allow who straddle the intersection of addicts to gain stability instead of public health and integrative med- relying on street heroin.71 The crisis icine are essential for advancing in the United States is fundamen- these kinds of integrative solutions tally different from Portugal, as it at the upstream policy level. did not start from over-prescriptions. However this serves as coun- The current opioid epidemic try a model in how harm reduction echoes a recurring pattern through- and public health efforts work. out human history: a physiological susceptibility to falling under the INTEGRATIVE MEDICINE AND spell of Papaver somniferum and its PUBLIC HEALTH derivates. With an so many under this spell in the United States in It is unlikely the United States will the current crisis, alternatives to be taking a decimalization ap- opioids and solutions for their side proach to the current opioid crisis. effects are needed. Integrative Instead the push must continue medicine, like acupuncture and to be on allocating resources into herbal medicine, offers remark- public health measures to see any able tools that can become an far reaching and equitable changes integral part of pain management in this opioid crisis. Moreover, a and opioid addiction solutions. decisive way for patients to get the However, for these modalities to improved care for pain and addic- be available to those who need tion is having integrative medi- them most, they must be part of cine fused into these programs. larger public health policies aimed Once informed of the benefits at prevention and access. Other of integrative medicine like acu- countries like Portugal have shown puncture, patients most often do that an approach based in public not choose use these modalities health and compassion can reduce because of cost barriers.52 Many the numbers of opioid related integrative medicine interventions overdose deaths.71 On the other are evidenced-based and would be hand, the punitive approach taken powerful complements to current by the United States in past drug programs or those being crafted to epidemics resulted in exacerbat- meet the needs of the crisis. Some ed racial disparities in health and examples of this could be acupunc- in the criminal justice system.57, 75 ture offered at more Methadone Therefore as policy makers debate clinics and free needle exchange how to approach this crisis, atten- sites, or integrative medicine tion must be paid to which groups offered as part of county mental these policies serve and who is left health facility programs. The in- with no options. Practitioners must clusion of Integrative Medicine as work together to continue build- it’s own department in primary care ing the research base and creating settings would make it easy for pa- inclusive programs to offer the tients coming in for pain manage- best integrative medical care to ment to access these services, like patients. Ultimate success could at Kaiser Oakland72, or in hospitals be measured in a number of ways like Highland Hospital in Oakland, including: reduction of opiate over- California.73 Additional research dose deaths, successful treatment is critical to continue building the of pain with safe alternatives, more evidence base for these modali- people in addiction recovery, im- ties, particularly herbal medicine.74 proved equitable access to health- With the allocation of resources for care, and resiliency in communi- researching treatments for addic- ties. As practitioners and policy tion and non-addictive therapies makers come into alignment on for pain, now is an excellent time how to address this complex issue, to fund research on integrative compassion is critical in creating medicine approaches.65 Practi- sustainable solutions for those in tioners already offering accessible desperate need. treatments, like community style acupuncture might be able to apply for state grants to continue REFERENCES offering these services to support opioid dependent patients. Also 1) Homer, RF. The Odyssey. New critical is advocating for acupunc- York: Vintage Books; 1990. ture coverage and adequate practitioner compensation by insurance 2) Prescribing Data | Drug Over- companies, from both government dose | CDC Injury Center. https:// AN INTERDISCIPLINARY PERSPECTIVE ON THE OPIOID CRISIS (CONT.) by Elena Roemer, DACM Candidate

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

web/20060823024931/http:// WHO. http://www.who.int/hiv/pub/ www.usdoj.gov/dea/pubs/his- guidelines/keypopulations/en/. tory/1985-1990.html. Published Accessed March 7, 2018. August 23, 2006. Accessed April 16, 2018. 70) United Nations: Criminal Sanc- tions for Drug Use Are “Not Bene- 61) Hart CL. Opinion | The Real ficial.” Drug Policy Alliance. http:// Opioid Emergency. The New www.drugpolicy.org/news/2014/03/ York Times. https://www.nytimes. united-nations-criminal-sanc- com/2017/08/18/opinion/sunday/ tions-drug-use-are-not-beneficial. Elena Roemer is passionate about opioids-drugs-race-treatment.html. Accessed March 7, 2018. integrative mental health and mak- Published August 18, 2017. Ac- ing medicine more accessible. She cessed March 7, 2018. 71) How to Win a War on Drugs - received her degree at UC Santa The New York Times. https://www. Cruz and while studying west- 62) Trump declares opioid epi- nytimes.com/2017/09/22/opinion/ ern herbalism and enthnobotany. demic a public health emergency sunday/portugal-drug-decriminal- Elena is a practicing herbalist and - CNNPolitics. https://www.cnn. ization.html. Accessed March 7, wellness coach based in Oakland, com/2017/10/26/politics/don- 2018. California, and will be completing a ald-trump-opioid-epidemic/index. doctorate in acupuncture and Chi- html. Accessed March 7, 2018. 72) East Bay Complementary & nese Medicine in Fall 2018. Alternative Medicine - Kaiser 63) Arkowitz SOL Hal, Arkow- Permanente. https://thrive.kaiser- itz SOL Hal. Why “Just Say No” permanente.org/care-near-you/ Doesn’t Work. Scientific American. northern-california/eastbay/de- doi:10.1038/scientificamerican- partments/complementary-alterna- mind0114-70 tive-medicine/. Accessed April 15, 2018. 64) Lee BY. Trump Declaring Opi- oid Crisis An Emergency Makes 73) Highlands Hospital » Integrative Just $57,000 Available. Forbes. Medicine. http://www.highlandshos- https://www.forbes.com/sites/bru- pital.org/services/integrative-medi- celee/2017/10/30/trump-declaring- cine. Accessed April 15, 2018. opioid-crisis-an-emergency-makes- 57000-available/. Accessed March 74) Ward J, Rosenbaum C, Her- 7, 2018. non C, McCurdy CR, Boyer EW. Herbal Medicines for the Man- 65) Cunningham PW. Analysis | agement of Opioid Addiction. The Health 202: Trump’s budget CNS Drugs. 2011;25(12):999-1007. shows he is serious about tack- doi:10.2165/11596830-000000000- ling the opioid crisis. Washington 00000 Post. https://www.washingtonpost.com/news/powerpost/palo- 75) Cooper HLF. War on Drugs ma/the-health-202/2018/02/13/ Policing and Police Brutality. Subst the-health-202-trump-s-budget- Use Misuse. 2015;50(8-9):1188-1194. shows-he-is-serious-about-tack- doi:10.3109/10826084.2015.1007669 ling-the-opioid-crisis/5a81de0130f- b041c3c7d780f/. Published February 13, 2018. Accessed April 15, 2018.

66) Trump urges death penalty for drug dealers. BBC News. http:// www.bbc.com/news/world-us-cana- da-43465229. Published March 19, 2018. Accessed April 12, 2018.

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69) WHO | Consolidated guidelines on HIV prevention, diagnosis, treatment and care for key populations.

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

ABSTRACT and states of either sexual hypo- or can be problematic to break from hyper-arousal, usually consciously tradition, as I am doing, and I hope In this article, I introduce a formula linked to abuse, substance abuse that readers with strong convictions that I have found very useful over patterns, or both. The continuity of about such matters will be patient the years in my herbal practice: relief that Modified Cinnamon Twig and recognize my interpretations Cinnamon Twig with Oyster Shell Formula brought about from both for a broader audience, which may and Fossilized Bone, or Gui Zhi Jia acute and chronic suffering has led bring about more alleviation of Long Gu Mu Li Tang, which I refer me to believe that this is a very suffering. In particular, it is import- to from here on out as Modified valuable tool when used appropri- ant to acknowledge that taking bits Cinnamon Twig Formula. I also give ately for providing support to indi- and pieces from traditional systems an introduction to a tradition of viduals experiencing these forms of without a broader context for appli- Chinese herbal practice that is at imbalance. cation may lead to injury of the pa- the heart of contemporary and clas- tient or no recourse for evaluation sical East-Asian herbal practice. I One of my main objectives, as well of the therapeutic methods when will present the modern indications as my hope and intention, is that they do not work. for the formula and, through case readers will find these methods examples, illuminate some possi- useful in relation to their existing INDICATIONS ble applications, some of which practice and that they might be apply directly to the references in motivated to study East-Asian herb- Zhang Zhong Jing first discusses the text and others that rely on my al medicine to learn the context in Modified Cinnamon Twig Formula in interpretation of clinical findings. which this formula is traditionally the Blood Impediment and Vacuity applied. Taxation section of the Jin Gui Yao Modified Cinnamon Twig originally Lue, or Essential Prescriptions from appears in the Prescriptions from My secondary aim in presenting the Golden Cabinet. The original the Golden Coffer, or Jing Gui Yao these cases and this formula is signs emphasized are seminal loss Lue, written by Zhang Zhong Jing to introduce the concept of har- with string-like tension in the lesser CE 220. Zhang Zhong Jing’s meth- monization to audiences of West- abdomen, yin head-cold, hair loss, ods of treatment, outlined in Trea- ern-trained herbalists and health- seminal loss for men, and dream- tise on Cold Damage (Shang Han care providers who may be aspiring ing of intercourse in women. The Lun) and in Prescriptions from the to offer herbs to patients and are pulse described is “scallion stalk,” Golden Coffer, emphasize warm- exploring a variety of paradigms stirring, and slightly tight. ing and supplementing therapies. within which to do so. Zhang Zhong Jing lived in an era Modified Cinnamon Twig is cat- of intense famine and his develop- HARMONIZATION IN TCM egorized in modern formularies ment and chronicling of this system under ‘Formulas that Secure and was in part a reaction to what he ‘To harmonize’ is defined in A Astringe’ and is primarily indicat- perceived to be deleterious treat- Practical Dictionary of Chinese ed for restraining incontinence of ment of disease with purgation Medicine as ‘To coordinate one urine and semen. The formula is therapies. element of the body with the rest also used for mental/emotional of the body or to coordinate two imbalances, particularly when there LEARNING OBJECTIVES elements of the body.’1 This can is an intersection with urological or refer to harmonizing organs in dis- gynecological complaints. Modern To introduce and explore the use of harmony with the rest of the body, lists of indications include: tension Modified Cinnamon Twig Formula organs in disharmony with each in the lesser abdomen, excessive as a method for treating various ex- other, or the reharmonization of sexual dreams, seminal leakage, pressions and origins of post-trau- physiologic phenomenon unique to cold in the head of the penis, im- matic stress disorder (PTSD) and Chinese medicine, such as harmo- potence, insomnia with excessive substance abuse, both together nizing constructive and nutritive dreams, bed-wetting in children, and separately. aspects of the body or harmonizing dizziness, palpitations, forgetful- lesser yang. ness, neurosis, hair loss, occasion- INTRODUCTION al watery diarrhea, generalized Each of the cases below exhibits weakness in physical strength and While I have studied and used this unique ways in which the formula condition, cold body, night sweats, formula for years, my interest in in question embodies principles a floating pulse, and muscle aches. it was invigorated around eight of harmonization. In particu- The presence of any of the above years ago when I began studying lar, this is an example where the symptoms or signs should point the the works of Zhang Zhong Jing with body is being supplemented and practitioner to consider Modified Dr. Arnaud Versluys through the strengthened while the mind and Cinnamon Twig Formula as part of Institute of Classics in East Asian nervous system are being sedated the treatment plan. Medicine and received a thorough and calmed. A simplified descrip- explanation of its origins and inclu- tion that Western herbalists may There are several signs and symp- sion in Jin Gui Yao Lue. Over the consider analogous would be the toms that occur in the source text following years, I began to observe concurrent use of adaptogenic or and other commentaries on the a few common patterns in individu- various ‘tonic’ herbs for building formula that I have found to can als for whom this formula appeared strength and nervines or sedatives be useful in interpreting whether to be strongly indicated. These ob- to relax and calm the mind and/or this is an appropriate for a given servations were based on tradition- the nervous system as it integrates patient. Several of these will be al methods of inquiry in East-Asian with specific organs. explored throughout the case his- medicine, including pulse and tories presented below. abdominal palpation, constitutional As this article may reach a diverse assessment via observation of habi- audience of herbal practitioners, it tus, and a standard inquiry of body is my intention to offer tools and INGREDIENTS AND ACTIONS functions. insight into methods that I have found useful in bringing relief of Cinnamon twig (gui zhi) 9g I began to see common denom- suffering. These methods utilize a White Peony root (bai shao) 9g inators of different expressions diagnostic framework that is over Fresh Ginger root (sheng jiang) 9g of post-traumatic stress disorder, 2000 years old and tools to bring Licorice root (gan cao) 9g often as sequelae of sexual abuse, about relief or resolution of dishar- Jujube date (da za) 12 pieces substance abuse withdrawal, a monies in multiple body systems, Fossilized bone (long gu) 9g history or concurrent use with which may not be treated concur- Oyster shell (mu li) 9g psycho-pharmaceuticals or illegal rently in other medical or healing narcotics seeking harm reduction, frameworks. I recognize that it

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

The formula is traditionally pre- tations. His pulse was floating and they use a preparation of Western scribed as a decoction, and the weak and upon abdominal palpa- Pasqueflower (Anemone occidenta- above dosages are those used for a tion exhibited pulsations in the lis)7, California Poppy (Eschscholzia daily dosage, three times per day. midline and below the navel. Neil californica), California Skullcap The formula is currently available is also HIV-positive and lives in a (Scutellaria californica), and Kava in the Western market in powdered neighborhood that he describes as Kava (Piper methysticum). This extract and pill form as well. “taking 5 years to grow accustomed seemed to abate the symptoms and to the amount of violence.” possibly bring the initial round of Modified Cinnamon Twig uses the attacks to a halt rather quickly. base formula, Cinnamon Twig De- Neil’s presentation has indications coction, to gently warm and nourish of both the Modified Cinnamon I have seen this grouping of herbs the body when it is necessary to Twig decoction and the base for- work effectively in numerous severe harmonize the interior and exteri- mula, Cinnamon Twig decoction. psycho-emotional crises and find it or of the body. This occurs in the I gave Neil five packets of the plausible that it was indeed respon- incidence of colds and flus where formula modified with 9g of kudzu sible for stabilizing the patient. I the body has insufficient resources (ge gen) to address the loose do not believe that this grouping to expel an externally contract- stools, tight neck and shoulders, of herbs has the potential to ad- ed pathogen, thus facilitating a and congestion then instructed him dress the underlying constitutional warm diaphoresis. The addition of to make one bag every day. Upon imbalance of this or other cases fossilized bone and oyster shell completion of the initial course of mentioned. I believe they have the astringes fluids, calms and settles herbs he appeared much more calm potential to be used in formula the mind, and assists the formula and rested. He reported his bowel with additional herbs to address in harmonizing the ascending and stabilizing and his head cold abat- the root imbalance, although that descending of qi and fluids in the ing, with reduced cravings for sex discussion is beyond the scope of body. In this case, the yang qi of and drugs. He also reported feeling this article. the kidneys fails to restrain the more energized and warm, and his fluids of lower orifices, resulting night sweats and palpitations had I then prescribed a variation of in leakage of water through the ceased. The pulse was still weak Modified Cinnamon Twig with the bowel, urine, and semen. At the but no longer floating, and the addition of sprouted wheat (fu xiao same time, the fluids unchecked abdominal pulsations had reduced mai). Sprouted wheat, along with cannot restrain the yang qi, which considerably. He and I agreed that licorice and jujube date, adds the ascends and creates a scenario in this formula suits his constitution indications of Licorice, Wheat, and which empty heat affects the mind, well and he continued to take the Jujube Combination (Gan mai da causing agitation and excessive formula, with the kudzu removed, zao tang) to the formulas. These dreaming. Cinnamon twig warms multiple days a week for several indications include frequent crying the yang or vital energy of the weeks. Later, he reported that it spells. A month elapsed between body while peony restrains and helps support a more restful sleep, the initial prescription and her con- nourishes the yin, or substantial reduces mental agitation, and that fiding that she had not taken the fluid aspect of the body. The func- it reduces his cravings and ideation formula and was continuing to have tions of these herbs both support about drug use. a difficult time. She let me know and attenuate each other’s effects. that she had begun to process her Ginger and jujube date support the Neil’s acute exacerbation of this own sexual abuse history, that it nourishing aspect of the chief in- presentation - a particularly exag- was at the root of her breakdowns, gredients, while licorice harmonizes gerated example of excessive sexu- and that she was actively in therapy the actions of the other herbs in al activity - is a primary etiology of for it. I had already begun writing the formula. In addition to calming the disease according to the source this article and forming impressions agitation and settling the mind, text. In combination with the use of of the value of Modified Cinnamon fossilized bone and oyster shell as- very depleting substances helped Twig in the treatment of PTSD and tringe leakage of sweat, urine, and to put both his constitution and sexual trauma and chose to tell her semen. As evident in the cases, the some of the aspects of his imbal- about it, which prompted her to formula is often further modified ance under the microscope. His intake the herbal prescription more to emphasize treatment of various somnia and mental agitation, night seriously. At of the time of this ar- aspects of the presentation. sweating, and palpitations are the ticle, she has been on the formula main expressions of the deficient for seven days, taking a bag of CASE STUDIES yin leading to yang ascending. His tea per day consistently, and she sensation of bodily cold, frequent reported that she immediately felt Case #1 urination, and loose stools were substantially more tranquil, warm, the main expressions of weak yang and supported since commenc- Neil is a patient I have treated losing control of yin. ing to take the decoction and is almost every week for the past enthusiastic about continuing with six years, primarily with acupunc- Case #2 it. Vivian is a somatic integration ture. He came to me a couple of therapist and expressed that the years ago with an acute head-cold Vivian was three-months postpar- formula has allowed her body to be accompanied by copious sinus tum following a difficult pregnancy a more “comfortable container for drainage and confided to me that and fragile neonatal experience for some of the complex emotions and he was coming down from a 48- both mother and child. In early Jan- experiences I have been visiting.” hour methamphetamine binge after uary she began to have panic at- seven years of sobriety (following tacks during which she experienced I think it is important to consid- 20-plus years of chronic metham- amplified ideation of the death of er the associated sign, “women phetamine and crack abuse). He her new baby. During the attacks dreaming of intercourse” from the was very anxious and described his she would become immobile and source text as an important guide drug abuse history as “related to cry inconsolably, including while for application of this formula for patterns of sexual compulsion that standing, remaining uncommunica- sexual trauma that remains a source stem from sexual abuse as a child” tive with her spouse for hours. She of discomfort for the individual and that in this binge he had in- described her body as very cold of any gender. I also believe it is dulged such behaviors and “wasn’t and “frozen” during the attacks, useful to cite the “birth as being dissatisfied with the results.” Upon and that this further escalated her analogous to the blood loss” etiol- inquiry, Neil reported feeling very sense of helplessness and fear. She ogy listed in the source text for the cold with tight neck and shoulders, experienced frequent urination and formula. Anxiety, panic attacks, and night sweats, and his stools were nighttime urination, but suffered intense fearfulness account for the quite loose. He hadn’t slept in 48 no hair loss. When I first received a ascending deficiency yang in the hours and was experiencing palpi- call about this I recommended that symptom picture, and the contract-

30 ing coldness along with frequent ent that those commonly employed, junction with constitutional sup- urination is indicative of yang defi- usually involving the use of sour, port): ciency cold. astringent herbs. The complication Rx medication: Vervain (Verbena of loose stools can also be inter- officinalis) + Skullcap (Scutellaria Case #3 preted as a descent of substances lateriflora) due to unsecured yang. Her con- Amphetamines and psychedelics: Ricki is a 24-year old female whose fusion, lack of focus, and frequent Western Pasqueflower (Anemone chief complaints are anxiety, fre- ideation of her trauma are all clear spp), Skullcap (Scutellaria lateriflo- quent urination, nighttime urina- signs of ascending yang due to lack ra), California Poppy (Eschscholzia tion, and occasional incontinence. of yin. californica), Hawthorn (Crataegus She has a history of sexual trauma sp.) and reports having frequent ide- DISCUSSION Alcohol: Kudzu (Pueria lobata) ation of this trauma that is disrup- tive to her daily life. She claims to Two common denominators found CONCLUSION have loose stools when she doesn’t throughout these three cases eat a celiac diet, which she tends indicate that Modified Cinnamon By virtue of these three examples, to not adhere to very well. The Twig is an appropriate formula for I think that with an appropriate patient had a very difficult time strong pulsations from the base of presentation, Modified Cinnamon making eye contact in the initial the sternum to the umbilicus and Twig Formula is an important for- session and seemed very startled pulsations just below and to the mula to look at in cases of PTSD. every time she spoke. I saw her in side of the navel. These are not I have prescribed this formula for an integrated clinic, so I had access modern indications for this formula several other patients who present to the background of her case in but rather are indications from the with a similar picture and report a chart notes from other physicians, Japanese herbal tradition called history of sexual or other trauma, including abuse history, counseling Kampo. Pulsations above the navel including those who have found status, and recommendations she in the midline are an indication for the limits of Western psychiatric received for natural therapies that the use of cinnamon and oyster pharmaceuticals and various forms were out of her price range. This shell, while pulsations below the of counseling. As patients may information enabled me to do a navel are an indication to use fos- not always conform exactly to the fairly efficient intake with someone silized bone, according to the 17th patterns that are studied, it is the who was admittedly uncomfortable century Japanese scholar Yakucho. responsibility of the practitioner speaking. It also enabled me to Early Kampo scholars are famous to interpret findings and corrobo- have a clear picture of the abuse for having united the practice of rate with the perspective of other history without having to probe for Fukushin, or abdominal palpation, physicians. By no means should a story. She also reported coldness, with the works of Zhang Zhong the reader interpret this to mean low energy, and scant menstrual Jing, where it continues to be uti- that this is a ‘go-to’ formula for periods. Pulsations in the midline lized in Japan’s national health care PTSD, but rather, it is meant to be of the abdomen and pulsations be- system. an example of how studying the low the navel were very strong and language of classical text from forceful, and her pulse was weak For the Western herbalist who is various conditions and eliciting the and floating. disinclined to use Chinese herbal correct interpretation, we can often medicine, I feel it is valuable to find solutions to common biomedi- Ricki was dispensed seven bulk extract the therapeutic principle cally-defined complaints that have packets of Modified Cinnamon Twig of harmonization from these cases only relatively recently been used Decoction and consumed these and formulas. It is not difficult to to define various phenomenon of over two weeks. Upon seeing her recreate formulas that are warming, the human experience. for the first return appointment she invigorating, and ascending that was very excited and eager to share simultaneously cool, relax, and de- Regardless of your herbal prescrib- her progress. She was much more scend agitated mental states utilizing proclivities, it can be of great lucid and articulate than during ing herbs domestically produced or utility to study styles with archaic our first meeting and described wild-harvested. Most of the herbs roots that continue to find expres- feeling much more energy, warmth, in the base formula Cinnamon sion in modern medical systems. and confidence in communicating Twig Decoction have already been In the case of this formula, the with others. She reported spend- commonly adopted into Western precedent exists in a text that is ing a lot less time in ideation herbal practice for decades or even 1800 years old and it is a currently about her trauma. She shared that centuries. Cinnamomum, Glycyr- prescribed in the medical systems she had not had any episodes of rhiza, and Zingiberis are all plants of several East-Asian nations. It is incontinence and that her urinary that are commonly available here in my intention that this article serves frequency had greatly diminished. the West. Paeonia is widely avail- as a bridge to readers taking in- Her pulse was still weak and hollow, able, though may not be as familiar terest in the formula itself and the and her abdominal pulsations were to some. therapeutic principles it embodies, reduced in strength. I have since as well as the formulaic style of continued her on the formula for WESTERN PLANTS USEFUL AS Zhang Zhong Jing. several months, which she takes POTENTIAL MODIFICATIONS: with a similar consistency. She REFERENCES states that it continues to support Palpitations: Motherwort (Leonurus her in the ways described above. cardiaca) + Western Pasqueflower 1) Wiseman N, Feng Y. A Practical (Anemone spp) Dictionary of Chinese Medicine. I believe that the etiology of this Taos, NM: Paradim Publication; case is related to the symptom Wind- damp pain and stiffness: 2014. in the source text of excessive Kava (Piper methysticum) + Black dreams of sexual intercourse, which Cohosh (Actaea racemosa) manifests as continual ideation of sexual trauma. This case illustrates Withdrawal, stiffness, and pain: clearly the primary contemporary Kava (Piper methysticum) + Pedicu- application of the formula of ‘se- laris (Pedicularis sp.) curing and astringing the urine’. Many herbalists and physicians will Urogenital discomfort and cold- note that this can be an extremely ness: Western Pasqueflower (Anem- difficult problem to treat and that one spp) the formulaic method for resolving the urinary problem is very differ- Substance use withdrawal (in con-

31 “SHEN-OCIDE”: TREATING THE PSYCHOSPIRITUAL ASPECTS OF OPIOID ADDICTION WITH ACUPUNCTURE AND CHINESE MEDICINE Mary Elizabeth Wakefield,L.Ac.,M.S.,M.M.,Dipl.Ac.,NCCAOM

ABSTRACT opioids illegally in 20134, and the INTRODUCTION number continues to grow! “Shenocide” is a coined word, Opioids are substances that are paralleling in structure the more In this article, we will focus on the used medically for both acute and familiar genocide, an English de- psychospiritual imbalances that re- chronic pain relief, for reversing rivative of the original Greek word sult from opioid addictions, which opioid overdose, and for suppres- “genos”, which means race. Geno- are precipitated by: sion of other symptoms. Some of cide is defined as the “deliberate the side effects of these drugs are: killing of a large number of people 1. Narcotic drug prescriptions for from a particular ethnic group or non-cancerous chronic pain, due to • drowsiness nation.”1 headaches, backache, fibromyalgia, • depression migraines and nerve pain; • euphoria In contrast, shenocide, the killing • hallucinations of Shen spirit, is not necessarily 2. The rise in misuse of illegal rec- • compromised immune system perpetrated by one group of indi- reational opioids for their euphoric • hormonal imbalances viduals upon another of a certain effects. ethnicity. However, opioid addic- Continuous use can foster depen- tion, which effectively destroys the As a palliative for these addictions, dency and tolerance to the drug; patient’s spiritual vitality, is re- three suggested acupuncture pro- this increases the need for higher sponsible for a growing number of tocols for Shen disturbances will be doses, and gives rise to intense deaths worldwide. Opioid addic- introduced, which can be integrat- withdrawal symptoms, when it is tion has reached epidemic propor- ed into your acupuncture practice, discontinued. Withdrawal symp- tions in the United States. Here in the context of a constitutional toms include: are some relevant statistics: treatment. • severe dysphoria - In 2011, an estimated 4 million The author has employed all three • manic raving people in the US used opioids treatment protocols to good effect, • depression recreationally and were addicted to not only for addictions, but also • irritability them.2 to treat Shen disturbances result- • nausea, vomiting, sweating - 23 million Americans needed ing from sexual, emotional and • tremors and insomnia treatment for addiction in 2012, spiritual abuses, possession, PTSD and only 2.5 million actually re- (Post-Traumatic Stress Dysfunction) Misuse of opioids can cause severe ceived treatment.3 and traumatic memory loss. psychological obsessions, and - Close to 38 million people used contribute both to lack of judgment

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MENTION THIS AD TO RECEIVE 25% off INITIAL ORDER OF OUR TCM LIQUID CONCENTRATES AND FORMULAS ous accidents and/or death. Since opioids have a sedative subdue her failed, the uncle was action upon the body, they can instructed by an unknown villager BACKGROUND depress the functioning of the re- to strike his aunt in her armpits. spiratory system, causing patients When he did so, she immediately The word “opioid” hearkens back to lapse into coma. If taken to collapsed, and, upon regaining to the earlier drugs classified as extremes, the heart will stop, and consciousness, she had no memory opiates, which are naturally derived death is the inevitable result. This of the incident. from the dried latex of the red pop- scenario is more likely to occur with py (Papaver somniferum), the prin- recreational drug usage. Dr. Chiang observes that this point cipal one of which is opium, lachry- in the axilla could only have been ma papaveris (literally, the “tears” A recent tragic case of opioid H1, jiquan, Summit Spring, the of the poppy plant). Historically, it abuse is that of the untimely entry point of the Heart meridian, was one of the most popular drugs passing of the rock star, Prince, and the abode of shen. For the gui used for medical, recreational and who died, according to the official to affect the shen, it needed to religious purposes. In the 3rd autopsy report, from a self-admin- invade the Heart. The pain that the century BCE, the Sumerians grew istered dose of fentanyl. Stories possessed woman experienced from poppies and harvested opium from later emerged in the media of the striking of this point caused the their seed pods, although the ear- clandestine visits to pharmacies in gui to depart and to return to its liest archaeological finds of opium the immediate vicinity of his Paisley original host. seeds date back to the Neolithic Park compound in Minneapolis, Era, approximately 5,000 years ago. likewise testifying to his strug- This story could serve as a met- gles with intense pain in his hips aphor for opioid addiction, be- In 1804, Friedrich Wilhelm Adam brought about by his onstage acro- cause it vividly describes the shen Sertürner, a German pharmacist, batics in the youthful heyday of his possession that is so apparent in first isolated morphine from the career. Prince’s wealth and fame addictive patients. Dr. Chiang also opium poppy, naming it after the made it possible for him to gain un- indicates that Ge Hong, the fa- Greek god of dreams, Morpheus. restricted access to excess amounts mous Taoist alchemist from the 4th Shortly after this discovery, codeine of opioids, and it seems evident century CE, used painful contact was similarly isolated from opium. that he was addicted to them above moxibustion to treat madness, rage In the 1850’s, the invention of the and beyond his need for relief from and epilepsy. Pain was intentionally hypodermic needle made possible his physical discomfort. Prince also inflicted on the body to resuscitate the injection of these and other reported in interviews that he had the shen disturbed patient, and substances into the body during suffered from epilepsy as a child, to dispel the gui/pathogen, which surgery, to address post-operative which is a hallmark of disturbed could be perceived in our era as an pain, and for general anesthesia. shen, according to Sun Si Miao. addiction to heroin, opium, mor- A doctor could then give a patient phine or any opioid. a rapid dose of a desired narcotic; THE OLD CHINESE AXIOM: for the recreational user, this trans- “THE SHEN LEADS THE QI” GUI: THE PERSONIFICATION OF lated into the notorious “quick fix” THE SHADOW of the drug addict. The shen, through the medium of thoughts and emotions, leads the Sun Si Miao (581-682 CE), Taoist Synthetic morphine derivatives flow of qi in our physical being. doctor and acupuncturist from the were formulated in the 20th cen- Shen being ethereal in nature, is Tang Dynasty, named entities which tury, and these substances were not as dense as the body, and thus, seek only material sustenance gui, called opioids, a word which means within this corporeal vessel, it can or ghosts. These entities can be “opium-like.” become stagnant. The associated either inherited predispositions emotions, if not expressed, lodge that we repeat throughout our lives CHINESE MEDICINE VS. WESTERN themselves in the cells, creating a without any awareness of their MEDICAL state of psychospiritual toxicity. If source, or they can take the form of this spiritual blockage is not moved addictions: opioid abuse, alcohol- In Taoist philosophy, the Three through the action of the qi, then ism, eating disorders, smoking, or Treasures refer to three intrinsic the person may seek something or any imbalance that imprisons the and inseparable forces that embody someone to help them forget their shen. Heaven (shen), Humanity (qi) and longing and emptiness. Earth (jing). In order to promote Gui can be regarded as the em- health, well-being and longevi- GUI: GHOSTS bodiment of the “dark” side of the ty, it was necessary to refine jing human psyche, forces and drives into qi, qi into shen, and shen into Poney Chiang, Ph.D., in an article, that remain unconscious. They openness. This was accomplished Spirits, Ghosts and Chinese Medi- also can be personifications of all in a transformative alchemical cine, 5 relates a fascinating account the haunted, suppressed qualities practice of lacing the three ji- of demonic possession, and how that we have stashed away in our aos with breath, meditation and a specific acupuncture point was emotional closets – judged by us acupuncture, and served to align utilized to expel a demon. Ap- as being negative, wrong, inferior, the practitioner with tian (Heaven) parently, a Tui-na doctor from scary or frightening. These forgot- and the Source. Any malaise, or an China witnessed his aunt exhibit a ten shards of ourselves have been addiction, was perceived as origi- superhuman ability, by which she shoved down “under the belt”, only nating in an imbalance in all three leapt upon the roof of the house. to emerge when abnormal stresses levels of being, and healing was This was followed by uncontrollable or pressures manifest to disturb our approached from a holistic per- dancing, as if she were possessed daily lives – death, loss of employ- spective. by a malign spirit. ment, divorce, etc. In contrast, Western medicine Her husband, a martial arts instruc- It is then that the gui emerge from tends to target the patient’s symp- tor, climbed up on the roof to bring those deep recesses of our being, toms. Consequently, as we have her down, however, she overpow- showing their faces to the light of noted previously, drugs are freely ered him and threw him off the day; these demons take control, prescribed for chronic, non-can- roof without any effort. Due to the manifesting as fright, fear, de- cerous pain, for long-term use; tremendous commotion, a crowd pression, rage, and even mania. this indiscriminate overmedication quickly gathered, and speculated The shen is disturbed and the gui can cause severe side effects and as to whether the doctor’s aunt was searches for something to dampen facilitate eventual addiction to the possessed by a specific demon. the pain, and uplift the spirit. At opioids. this time the euphoric effect of After several other attempts to opioids may seem attractive to the suffering person. 33 “SHEN-OCIDE”: TREATING THE PSYCHOSPIRITUAL ASPECTS OF OPIOID ADDICTION WITH ACUPUNCTURE AND CHINESE MEDICINE (CONT.) Mary Elizabeth Wakefield,L.Ac.,M.S.,M.M.,Dipl.Ac.,NCCAOM

and dangerous behavior, i.e., seri gy™. The latter course utilizes Acu- artistry, and sense of humor. Sun Si Jung would have regarded the tonics® tuning forks on the points Miao referred to a “ghost evil” as gui as being synonymous with the and meridians of the body, instead a disorder associated with demonic shadow, because it represents all of needles. These points are ex- possession, and offered the follow- the orphaned, disembodied, reject- tremely effective when integrated ing associated symptoms: ed aspects of ourselves. into a constitutional treatment, and address anything that imprisons the Seeing ghosts: delusions of ghost- Giovanni Maciocia has observed6 spirit. like imagery; hallucinations that the Chinese characters for Ghost talk: delirious speech, rant- both the Hun, the Ethereal Soul, Sun Si Miao first documented these ing and raving and the Po, the Corporeal Soul, points in his 7th century work, The Floating ghost talk: mental unrest, contain the radical for gui, and Thousand Ducat Formulas. They disruption of the spirit that these souls are independent relate to the removal of energet- Floating corpse talk: delirium man- of the mind. In my opinion, this ic blocks and emotional fixations, ifesting during the terminal stages means that humanity possesses and alleviate symptoms of manic of tuberculosis free will, or a choice as to how they depression, epilepsy, fright, bipo- Mad Ghost walking: disturbed sleep live their lives. However, while the lar syndrome, mental unrest and walking path of opioid use may originate disturbed Shen, all of which are in conscious choice, this addiction categorized as forms of possession. All the Ghost points address these eventually robs the person of their The treatments employ a combina- manifestations of disturbed shen; capacity to choose, stripping them tion of needles, moxa and bleeding some of them expel internal and of their dignity. They are not in techniques. external wind, restore conscious- control of their impulses, and the ness and clear heat: demons take hold of the “dark forc- I do not recommend that the prac- es” of the psyche. titioner use all 13 of the points in one session, unless exceptional GUI: THE 13 GHOST POINTS circumstances should indicate that they do so. I usually rotate 2 or 3 I have used Sun Si Miao’s 13 Ghost Ghost points in each session, and points in my practice and have integrate them into a constitution- taught them to students in the al treatment protocol, focusing on Alchemical Level of the 2-year anchoring the yang qi and nurtur- International GOLD STANDARD FA- ing the yin. CIAL ACUPUNCTURE® Certification Program at Northwestern Health In my research, I discovered Sun Sciences University. I have also Si Miao’s Ode to Needling the 13 included them in the curriculum of Ghost Points,7 translated into En- a course that I co-created with my glish. Apparently, the Ode rhymes partner, MichelAngelo, Vibrational beautifully in ancient Chinese, and Medicine: 5 Element Intergenera- provides an ample demonstration tional Patterns and GeneAstrolo- of its author’s knowledge, skill, A RARELY USED dresses emergency conditions, and REFERENCES PSYCHOSPIRITUAL POINT: SJ 2, being a yin point, also treats blood YEMEN, FLUID GATE and shen imbalances, because the 1) Oxford English Dictionary. Ox- blood rules the shen. This makes ford University, 2013, pp. 379-80. The second treatment protocol in- it a perfect point for manic de- volves SJ 2, a ying spring point that pression, fear, fright and chemical 2) Report III: FDA Approved Medi- clears heat from the upper body. It toxicity that can arise from opioid cations for the Treatment of Opiate could have been, in my opinion, a addiction. Dependence: Literature Reviews on 14th Ghost point, although there is Effectiveness & Cost- Effectiveness, no reference to shen in its name. K 27, shufu, Shu Mansion, is the Treatment Research Institute”. Ad- Kidney transporting shu point, vancing Access to Addiction Medi- It is useful in the treatment of where the qi of the Kidney is cations: Implications for Opioid Ad- local pain, heat and swelling of the collected. It is a mansion that diction Treatment. p. 41.; accessed back of the hand, with contracture abundantly contains Kidney qi and 1/10/18. of the five fingers, referred to as essence. DePuytren’s Syndrome. The San 3) Tetrault, Jeanette M.; Butner, Jiao meridian ascends to the head, Indications: Jenna L. (2015-09-03). “Non-Med- the outer canthus of the eye, and ical Prescription Opioid Use and enters the ear, therefore this point Long term addictions, which dam- Prescription Opioid Use Disorder: A also addresses tinnitus, deafness, age the Kidneys Review”. The Yale Journal of Biol- earache, headache and other symp- Opiate addiction: opium, heroin, ogy and Medicine. 88 (3): 227–233; toms of heat imbalance. It can also morphine, codeine and opioids accessed 1/10/18. be very effective in the treatment Shen disturbances of Shen disturbances. Overuse of steroid hormones 4) “Status and Trend Analysis of Il- Overuse of anti-inflammatory drugs lict [sic] Drug Markets”. World Drug Functions: Report 2015; accessed 1/10/18. Needling Protocol: Moistens the mucuous membranes 5) Poney Chiang, “Spirits, Ghosts and regulates fluids in the upper Japanese K 9, zhubin, is 3 cun and Chinese Medicine. Oriental body below K 10, yinggu. Needle K 9 Medicine Journal, New Year edi- Calms heat and benefits the eyes perpendicularly and bilaterally, or tion, January, 2008, 25-31. and ears use direct moxa. Calms the shen 6) Maciocia, Giovanni, The Psyche K 27, shufu, is needled bilaterally in Chinese Medicine: Treatment of Indications: and transversely toward the Ren Emotional and Mental Disharmo- Mai, the sternum. nies with Acupuncture and Chinese Red and dry eyes and face Herbs. London: Churchill Living- Palpitations, frayed nerves, epilep- Retain these needles in the body stone Elsevier, 2009. sy, insomnia, shortness of breath, for the entire constitutional treat- and psychospiritual imbalances ment unless otherwise indicated. 7) Dale, Ralph Alan, Acupuncture: The Special Function Points. North SJ 2 is the Water point on the Fire CONCLUSION: A FEW INSIGHTS Miami Beach, FL: Dialectic Publish- channel, and it transports fluids ing Inc, 1996. to the face and head, which cools, “The non-medical use of prescrip- moistens and calms this area of tion drugs has been fueled by the 8) Andrew Ellis, Nigel Wiseman and the body. The San Jiao exterior/ medical community’s over-reliance Ken Bass, Grasping the Wind: An interior relationship with the Peri- on the use of prescription opioids Explanation into the Meaning of cardium, which wraps around and to treat both acute and chronic Chinese Acupuncture Point Names. protects the Heart, the abode of pain.”9 Both medical and non-med- Brookline, MA: Paradigm, 1989. shen, allows SJ 2, yemen, to treat ical use of opioids has escalated a patient who is unable to “go with in recent years, and addicts have 9) Tetrault and Butler, op. cit. the flow”, one who lacks fluidity in now progressed to heroin and other their life. drugs to “kill” physical and psychospiritual pain. It is important For more serious psychospiritu- for us, as acupuncturists, to collab- al manifestations, such as manic orate with doctors, therapists and depression, manic raving, ceaseless other healthcare professionals in laughter or weeping uncontrollably, treating and addressing this para- I needle this point in tandem with lyzing wound in our society. Sun Si Miao’s fourth Ghost point, P 7, gui xing, Ghost Heart. “We are representatives of a medical tradition that has endured for This powerful combination cools thousands of years, that makes use and moisturizes the head, face and of both logic and intuitive insight. sinuses, and clears heat from the Oriental medicine is both an art Heart, calming the shen. and a science; it respects individual differences and the significance of Mary Elizabeth Wakefield, L.Ac.,M. A JAPANESE TREATMENT FOR specific patterns or archetypal im- OPIOID ADDICTION balances that may arise during the S.,M.M., is the internationally rec- course of treatment.”10 ognized author of the book, Consti- This third protocol was originally tutional Facial Acupuncture (Else- designated for opiate abuse, and We know how to treat imbalances vier UK, 2014). She has 30+ years addictions that toxify and damage of qi, addictions and fixations on of clinical experience, and has the Kidneys. The first point nee- both the physical and psychospiri- personally trained 5,000 healthcare dled is Japanese K 9, zhubin, Guest tual levels, and can compassionate- practitioners from 5 continents. House. In Grasping the Wind,8 it ly educate patients about change, is explained that the radical zhu choice and the possibility of heal- means to “attack” and the radi- ing and transforming their lives. cal bin means “to expel”, i.e., the pathogen from the Kidneys. Zhubin is a xi-cleft point which ad-

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

ABSTRACT studies about how inflammation is regulated by the autonomic Research suggests acupuncture nervous system and studies that Keywords: Autonomic nervous down-regulates inflammation. But indicate acupuncture may active- system, immune regulation, what are the mechanisms that drive ly participate in the regulation of inflammation, cytokines, this process? In this essay, I review inflammatory cytokines. acupuncture

MAKING THE CASE: ACUPUNCTURE MODULATES THE AUTONOMIC NERVOUS SYSTEM

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

In the above illustration, the blue lines signify the effects of acupuncture on an inflammatory condition. Disorders such as stress, indigestion, irritability, or pain can indicate the effect of mild inflammation.

Can ‘the inflammatory reflex’ which research indicates rebalances the autonomic nervous system be applied to the acupuncture effect? Does the acupuncture treatment act as a distributed connection that affects both the autonomic nervous system and the immune system?

36 Recent studies indicate that health Nakai of Osaka University reported while efferent fibers project from is a delicate balance between the T-Cells, affected by sympathetic the nucleus ambiguous (branchial) autonomic nervous system and cy- stimulation refrained from entering and dorsal motor nucleus. While tokine production. Overproduction the wider immune system.5 Lorton the sensory afferent fibers in the of cytokines can result in critical and Bellinger6 found that sympa- brainstem terminate in the nucleus and severe disease such as sepsis, thetic nerve pathways are modified tractus solitaries, they send fibers rheumatoid arthritis, or ulcerative by immune disorders. There seems that connect either directly or indi- colitis. Research1 indicates that by to be agreement by scientists that rectly to different brain regions.7,8 stimulating the vagus nerve, cyto- there is no direct neural connec- Afferent signaling of the vagus kine production can be diminished. tion between the vagus nerve and nerve also activates the hypothal- Sensory input elicited by injury or spleen, but vagal stimulation mod- amus and other CNS nuclei, which infection travels along the affer- ulates sympathetic activity and the regulate the neuro-hormonal HPA ent branch of the vagus nerve to immune system.5 axis. These neurons are associated regions of the brainstem, and the with glucocorticoid production. brain carries outbound signals that The research, involving the au- The signals are also relayed to the effect the spleen and other re- tonomic nervous system, can be cell bodies of the efferent para- gions of the immune system. Some utilized by acupuncturists in both sympathetic vagus nerve, which of research by Zhou2 and Torres3 treatment design and explanations are located the medullary nucleus suggests that acupuncture may about treatment effect to doctors ambiguus.1 down-regulate the immune system and patients. This essay reviews through the autonomic nervous some seminal research not only In the heart the baroreceptor reflex system. about how the autonomic nervous is activated by increases in blood system interacts with the immune pressure, which stimulate stretch In an article published in 20004, Dr. system, but studies that indicate receptor in the carotid sinuses and Kevin Tracey injected a chemical a place for acupuncture in this re- aortic arc. These receptors trigger into a rat brain, which activated search that adjusts inflammation in action potentials transmitted along the vagus nerve, resulting reduc- peripheral tissues. the vagus nerve to the brainstem tion of tumor necrosis factor (TNF) and other nuclei, which modulate throughout the body. In that same A BRIEF REVIEW OF THE VAGUS outgoing blood pressure responses. article, the author describes how in NERVE These include decreased signaling another such experiment, Tracey in- to adrenergic nerves to the heart, jected endotoxin in a rat, a pro-in- The vagus nerve is the key com- reducing contractibility and heart flammatory bacterial toxin typically ponent of the parasympathetic rate, while maintaining blood pres- resulting in body wide inflammation system, comprised of sensory and sure within a narrow homeostatic and sepsis. He then electrically motor fibers or afferent and effer- range.1 stimulated the vagus nerve, reduc- ent pathways. The afferent portion ing TNF, thereby reducing inflam- of the vagus nerve is far great- The vagus nerve fibers innervating mation. He and other research er – eighty percent of the vagus. the upper and middle gastrointes- scientists performed a series of It monitors autonomic activities tinal tract originate from two nuclei experiments on animal models4, such as heart rate, blood pressure, in the brain stem. The nucleus demonstrating that the vagus nerve breathing, digestion. While the ambiguous nucleus which reaches when activated with electrical afferent portion is relaying im- the larynx and esophagus, and the stimulation affects the spleen’s portant sensory information to the dorsal motor nucleus of the vagus depository of immune cells. From brain, the efferent fibers, which are which reaches the stomach and the there, David Felton, a neuroanato- cholinergic, are activating parasym- descending colon.9 There is some mist captured microscopic images pathetic activity in the heart, lungs, suggestion9 that ‘the macrophages of hybrid neuron T-cells synapses, liver, stomach and upper portion of located between the longitudinal not only in the spleen, but thymus the large intestine. Afferent fibers and circular muscled layer at the and lymph nodes which responded project to the nucleus tractus soli- level of the myenteric plexus act to sympathetic transmission. Akiko taries (visceral, sensory, and taste), as the gatekeepers of the enteric

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

nervous system. The enteric ner- brain and area of inflammation can from the spleen during a peritoneal vous system forms a dense network be modified by a stroke; doctors infection.10 of nerve cells near many immune and scientists10 have noted other cells. Theory suggests the choliner- evidence of inflammatory reduction Neither cytokines, their receptors, gic tone affects the enteric nervous in the region of paralysis of a pa- or neurotransmitters behave in a system, and vagal innervation may tient with an inflammatory condi- simple digital manner. There is a modulate the intestinal environ- tion such as rheumatoid arthritis. profound dialectic of cross talk ment by any immune cell carrying a In patients10 who have had even a between them6; receptors respond- cholinergic receptor.9 minor stroke or poliomyelitis, their ing on the surface of immune cells immune response is altered on the to neurotransmitters, cytokines THE SYMPATHETIC IMMUNE affected side. In rat models, a sym- affecting nerve endings which in RESPONSE phathectomy leads to a reduction turn affect the autonomic nervous in infection rates.10,16 system and sensory nerves; out- The sympathetic nervous system put and input juggling a conver- and the immune system are tight- It has been shown that second- sation between what is both local ly intertwined. There is a large ary lymphoid tissue, such as the and central. There are no simple body of research10 demonstrates spleen, is innervated by sympathet- caveats such as norepinephrine is the autonomic dysregulation can ic nerve fibers, and nerve termi- pro-inflammatory. Neurotransmit- drive inflammation by inciting the nals within the vicinity of immune ters may contradict one another’s immune system. If the signal from cells.10 Immune cells express re- messaging, and to add to the mix, nerve fibers is strong enough or if ceptors for neurotransmitters. One the sympathetic nervous system local inflammation mediators spill such group of transmitters on im- is directing nonimmune cells to into broader circulation such as mune cells has been named adreno- reduce the inflammatory process, lymph and blood, the hypothalamus receptors (AR). There are many sub- while redefining input from sensory pituitary adrenal (HPA) system and classes of adrenoceptors on nerve nervous system.6,10 the sympathetic nervous system endings and other kinds of tissue, activates.10 including receptors that activate THE INFLAMMATORY REFLEX: the immune system by responding THE VAGUS NERVE GUIDES THE When an antigen enters the body, to adrenergenic stimulation.17 TNF IMMUNE SYSTEM local immune cells are activated, was the first of many cytokines that leading to the release of pro-in- was shown to respond to catechol- In this complicated electro-chem- flammatory cytokines and che- amines that belong AR category.10 ical conversation, the vagus nerve mo-messengers such as the tumor plays a prominent role in suppress- necrosis factor (TNF), Interleukin1 Sympathetic nerve endings release ing inflammatory cytokine chat- (IL1) or Interleukin6 (IL6).11 Cy- not only norepinephrine, but ni- ter. Dr. Tracey has described this tokines are small non-antibody trous oxide, neuropeptide y (NPY), phenomena as ‘the inflammatory proteins secreted by various im- and adenosine triphosphate, ATP. reflex’.1 The vagus nerve terminates mune cells including macrophages, While norepinephrine may be the in the celiac ganglion, never reach- T-Cells, B-Cells, dendritic cells, best understood neurotransmitter ing the spleen; however, electrical endothelial cells, fibroblasts and affecting the immune system, it stimulation of the vagus nerve stroma cells. Cytokines are not per- has also been shown that an NPY above the celiac ganglion or the sonalized by exposure to antigens antagonist reduces inflammation in splenic nerve significantly inhibits like antibodies.11 rats with chemically induced rheu- TNF production in the red pulp and matoid arthritis.10 Immune cells can marginal zone macrophages of the These chemo-messengers regulate be directly affected by the sympa- spleen. Nerve fibers in the spleen immune response. Critical condi- thetic nervous system through their that originate in the celiac gan- tions including sepsis, some cancer, own adrenoceptors, or indirectly glion are adrenergic, responding trauma, rheumatoid arthritis, and influenced through flow of blood or to norepinephrine as the primary heart disease12 are the result of lymph, whereby they regulate the neurotransmitter. The vagus nerve an over-response of the immune production and distribution of lym- situated upstream from the sym- system. The cytokines, TNF (alpha), phocytes, or modulate pro-inflam- pathetic celiac ganglion, somehow Il6, and Il1 are elevated in almost matory peptides such as substance activates nicotinic acetycholine all inflammatory states and recog- P elicited from sensory nerve receptors (nACH7) on macrophages nized targets for treatment in many endings.10 that respond to the neurotransmit- of the new biologic drugs entering ter acetylcholine which substantial- the market.11, 13 The chemo-sig- The sympathetic nervous system ly down-regulates TNF.20 nals can either excite or lower the is involved in changes in leuko- thresholds for sensory pain recep- cyte distribution and immune cell Within minutes of Tracey et al. tors and sensory vagal nerve fibers. recruitment throughout the body. applying electrical stimulation A recent tissue study13, showed to the vagus nerve, acetycholine Communication between the that Beta AR’s (beta adrenoceptors) levels were elevated, reaching a brain and immune system toggles were expressed on non-hematopoi- peak twenty minutes later. These between levels of cytokines. For etic cells, leading to the expression scientists postulated that perhaps example, in a study14 involving of endothelial cell adhesion mole- lymphocytes synthesize and release hypertensive medication of meno- cules and chemokines; a significant the neurotransmitter in response to pausal women, reduction in blood step in accelerating an inflammato- norepinephrine. They also postu- pressure down-regulated sympa- ry response. This pathway can be late that these T cells are located thetic activity, thereby reducing a stepping stone toward degener- not only in the spleen but Peyer’s TNF serum levels. In another study- ative disease such as atherosclero- patches and lymph nodes, widen- 15down-regulating the sympathetic sis18,19 or the formation of second- ing the influence of vagus nerve system coincided with a reduction ary cancers.13,19 In another study signaling.20, 21 in IL-6.10 Other research10 shows the sympathetic nervous system that communication between the effected recruitment of monocytes Reduced heart rate variability (HRV)

38 is a symptom associated with a is sensory, information goes in the suggest the heart rate variability rise in cytokine levels. This may brain; second is efferent (leaves the may qualify as an indicator at who be prompted by both Pathogen or brain) and cholinergic. The cholin- may be at greater risk for high lev- Danger Associated Molecular Pat- ergic efferent branch of the vagus els of inflammation. terns (PAMP or DAMP).22,23,1 Many travels near the celiac sympathetic acute and chronic inflammatory ganglion, which connects to a third STUDIES THAT DEMONSTRATE disease are associated with such adrenegic neuron. This connects to ACUPUNCTURE DOWN-REGU- molecular patterns and accompa- the splenic nerve to deliver nor- LATES INFLAMMATION nied by a reduction of heart rate epinephrine to Beta-2 adrenergic variability. These include sepsis24, receptors expressed on a subset of In recent study by Zhou et al.2 func- hemmorhagic shock25, myocardial T-cells capable of secreting acetyl- tional dyspepsia and gastric emp- infarction26,27, rheumatoid arthritis28, choline. T-cells are acting in place tying were measured in rat pups or ulcerative colitis29,30, but also of cholinergic neurons, activating before and after auricular elec- conditions like metabolic syndrome the nACH7 receptors expressed on tro-acupuncture. Gastric distension or diabetes31. Tracey and his col- cytokine producing macrophages. or functional dyspepsia was rated leagues have shown that by intro- This occurs in marginal zone and by behavior indicating discomfort. ducing endotoxin into a rat perito- red pulp of the spleen. These Autonomic functions were assessed neal cavity, there was a reduction in macrophage nACH7 receptors then from the spectral analysis of heart heart rate variability. Vagal signal- suppress cytokine transcription and rate variability derived from an ing was conjoined to HRV response, release.35 The efferent vagus nerve electro-cardiogram. Functional dys- and reduced the response of innate indirectly modulates the immune pepsia diminished in rats treated immunity.1, 32 response. with auricular electro-acupuncture but gastric emptying was not Dendritic cells, releasing Interleu- altered.2 kin (IL-1Beta) and prostaglandins, are located within vicinity of vagus Other avenues were explored by nerve fibers. Injection of bacte- Zhou et al. Two different sets of rial endotoxin or administration electrical prescriptions were imple- of IL-1Beta, a cytokine, activated mented, indicating that the fre- afferent vagus neurons. These sci- quency of electrical stimulation has entists posit that signals through a consequence on treatment effect. the afferent vagus nerve reach the These prescriptions were based on nucleus tractus solitaries in the the work of Han et al.38 that demon- brainstem portion of the medulla. strated the combination of two fre- This is where interconnections to quencies, 2 hz and 100 hz produced the dorsal motor nucleus of the all 4 opioid peptides, enhancing vagus nerve efferent vagus nerves the effect of electrical stimulation. fibers originate. Tracey et al. have Sun et al.39 used Han’s prescriptions demonstrated that there is afferent to reduce visceral sensitivity in rats nerve activity in the thymus and with gastric ulcer. This research the splenic nerve as a response to of Han and Sun was the basis of interleukin IL-1beta and endotox- Zhou’s choices in choosing frequen- in.31,33 cies for reducing gastric dyspepsia.

Ninety-four percent of TNF re- Naloxone was injected intraper- leased systemically in early phase itoneally into the rats before toxemia in a rodent model origi- electro-acupuncture treatment to nates in the spleen, and has been examine the opioid mechanism.2 shown the splenectomy protects Surprisingly, the drug, an opioid against the lethal effects of sep- antagonist, did not block the ef- sis.34 Dr. Tracey and colleagues fects of auricular electro-acupunc- make a case that the spleen is the ture on the autonomic function. primary target for signals from the This illustration describes the In a previous study40, Zhou and efferent arm of the vagal neurons. inflammatory reflex — the pathway colleagues determined electro-acu- Within the celiac plexus ganglia, for reducing cytokines by adjusting puncture at ST 36 mediated both vagus nerve fibers transmit in- the inflammatory response in the autonomic and opioid pathways, formation through interneurons spleen. Acetylcholine, the major but also operated independently or postsynaptic cate-cholinergic vagal neurotransmitter, diminished from the opioid pathway. Naxlox- neurons. While the central ner- the release of TNF and interleukins one did not inhibit the treatment vous system transmits signals from (IL-1 beta, IL-6 and Il-8).1 effects in this study2; and auricu- sympathetic chain, accumulating lar electro-acupuncture increased data1,3,21,33 indicates the vagal ef- It is the vagal efferent signal that vagus nerve activity and improved ferent signaling is required for the activates macrophages that also sympathovagal balance. inflammatory reflex to occur. The modifies heart rate variability. The inflammatory reflex response is nei- cholinergic response to nACH7 Zhou et al. devised two sets of ther classically parasympathetic nor receptors slows the heart rate via electrical prescriptions. The first sympathetic but an amalgamation the muscaric cholinergic receptors was based directly on the work of of neural communication.33,34 on heart pacemaker cells.36 Vagus Han and Sun. This provided inter- response increases the variations mittent frequency of 2 hz and 100 Just to review, presently, research- between heartbeats. The lack of hz. Besides inducing opioid path- ers think the circuitry involving va- heart rate variability can be an in- ways, Sun had shown this protocol gus input finishes on cytokine pro- dicator of autonomic dysregulation. reduced visceral hypersensitivity.39 ducing macrophages. First neuron Dr. Tracey and other scientists37 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 consistently shown off, at 25 hertz.2,40 Interestingly, re- puncture was reported to improve to reduce gastric emptying. It con- searchers discussed another study41 rectal distention induced gastric sisted of 2 seconds on, 3 seconds in which auricular electro-acu- dysrhythmias.

In another recent animal study at VAGUS NERVE THERAPY engaging only the vagus nerve.44 Rutgers University study by Torres, Rosa, and Ulloa, et al.3 demonstrat- Electrical devices, often surgically The auriculotemporal, greater ed electrically stimulation of ST 36 implanted micro cuffs, are now em- auricular and auricular branch of ployed in the treatment of epilepsy, the vagus nerve innervate the ear. (Zu San Li) at 10 Hz, in continuous depression, and rheumatoid arthri- The cymba conchae of the ear is mode activated the common tibial tis. Electrical stimulation of the left innervated exclusively by auricular and peronal branches of the sciatic vagus nerve is an approved therapy branch of the vagus nerve. Patients nerve. In this electro-chemical for epilepsy. Some studies7 sug- can self-administer treatment di- thread, Zu San Li St 36 by way of gest that low amplitude (<1.5mA) rectly to the cymba concha. Such a the sciatic nerve leads to produc- and high frequency (20 hertz) stim- device has already received Euro- tion of dopamine in the adrenal ulation is effective for depression. pean government clearance for the medulla. These results suggest the The device most commonly em- treatment of epilepsy and depres- ployed is a battery powered pulse sion. A TENS (transcutaneous elec- production of catecholamines is generator that requires a surgical trical nerve stimulator) can also be moderated by the vagus nerve. Do- implantation. The generator is in- used to stimulate the cymba concha pamine inhibits cytokine production serted subcutaneously in left upper either unilateral or bilateral.44 by dopamine (D1) receptors in the chest wall, while an electrode wire medulla indicating another path of is attached to the left mid-cervi- Another device includes contact vagus nerve interference. As dopa- cal vagus nerve through a second pads that are placed over both mine production can modulate the incision in the upper left region branches of the vagus nerve in the immune system, animal studies sug- of the neck. A handheld comput- region of the upper neck. The in- er programs the pulse generator. tensity of the stimulation is direct- gest electro-acupuncture at Zu San Unfortunately, stimulation of the ed by the patient with a handheld Li ST 36 post-surgically decreases mid-cervical vagus nerve may affect device. This design is intended to inflammatory cytokines.3 the voice, breathing, swallowing relieve cluster and migraine head- and the neck. It also generates aches. The USDA (FDA) recent- uncomfortable sensations of pares- ly approved a similar hand-held thesia in the upper body. Electrical device called, gammaCore, for the impulses generated at area have treatment of cluster headaches in a greater effect on the brain since adults. In a small study45 patients the bulk of nerve fibers are affer- were pain-free in 15 minutes. ent.7 SetPoint Medical Devices devel- Recently, an Israeli company de- oped by Dr. Tracey and his col- veloped a cuff designed to circum- leagues initially modified a stimu- navigate the vagus nerve. This new lator designed for the treatment of design favored activation of vagal epilepsy. They have demonstrated efferent fibers that affect cardiac the macrophages hit by acetylcho- function in the right chest wall. So line are unable to produce TNF far, studies7 (preclinical, and phase for up to twenty-four hours. Addi- II) indicate this device is safe. The tionally, vagus nerve fibers require same cuff was re-engineered for very low electrical stimulation, the left side of vagus. Five patients approximately one eight typically were treated for epilepsy with required for epilepsy to respond the newly designed cuff and side to a treatment. In 2011, SetPoint effects in the upper region of the Devices5 were tested on human body diminished.7 There is some subjects in Amsterdam and at the anatomical evidence that the right UK-based pharmaceutical company cervical vagus nerve stimulation has GlaxoSmithKline. Over the course a greater effect on the heart, but of several years eighteen people treatment for heart failure using with rheumatoid arthritis enrolled such devices has not be particularly in the study. Twelve participants successful. The cervical neck area stated their symptoms improved The effects of electro-acupuncture contains abundant sympathetic over six weeks. Lab tests demon- at Zu San Li T 36, describing how fibers, particularly the right vagus strated the blood levels of inflam- by activating the sciatic nerve, nerve, indicating both sympathetic matory molecules, such as TNF systemic inflammation was reduced and vagus nerves travel in a com- and IL-6, decreased. Improvements mon trunk. Others posit that trans- vanished when the devices were by vagal activation of a dopamine 3 cutaneous stimulation of the vagus shut off for two weeks, but returned precursor in the adrenal medulla. nerve in the ear might be a better when stimulation was restarted.5 Dr. avenue for treatment, preferentially Bruno Bonaz46, a gastroenterologist 40 from Grenoble, was treating seven accumulate in the future, research anti-inflammatory properties of the people with Crohn’s disease. Five science has generously provided us cytokine interleukin-6; Biochimica people reported fewer symptoms, with a convincing umbrella to stand et Biophysica Acta (BBA) - Molec- and endoscopies showed reduced beneath. We must master and de- ular Cell Research; https://doi. tissue damage. The study was never fine our place in this new paradigm org/10.1016/j.bbamcr.2011.01.034 published. SetPoint is also en- of treatment. gaged in a clinical trial for Crohn’s 12) Hanoun M, Maryanovich M, disease.5 REFERENCES Arnal-Estapé A, Frenette PS. Neu- ral regulation of hematopoiesis, Will electro-ceuticals be the next 1) Tracey KJ. Reflex control of inflammation and cancer. Neuron. treatment breakthrough? Electrical immunity. Nature reviews Immunol- 2015;86(2):360-373. doi:10.1016/j. stimulation of the vagus nerve is an ogy. 2009;9(6):418-428. doi:10.1038/ neuron.2015.01.026. accepted treatment, and medical nri2566. devices are being marketed in Eu- 13) Smith CW1, Endothelial adhe- rope, Israel, and the United States. 2) Jingzhu Zhou, Shiying Li, Yinping sion molecules and their role in Glaxo Smith Kline is partnering Wang, Yong Lei, Robert D. Fore- inflammation; Can J Physiol Phar- with Google. US National Institute man, Jieyun Yin, Jiande D. Z. 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41 CAN ACUPUNCTURE BIO-HACK THE AUTONOMIC NERVOUS SYSTEM AND DOWN-REGULATE INFLAMMATION? (CONT.) Dr. Sharon Hennessey, DAOM, L.Ac.

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