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Increasing retention
rates among the chemically dependent in residential treatment:
Auriculotherapy and subluxation-based chiropractic care. Jay M. Holder,
Robert C. Duncan, Matthew Gissen., Michael Miller, and Kenneth Blum,
American College Of Addictionology & Compulsive Disorders, Miami
Beach, Fl., University of Miami School of Medicine, Miami, Fl.,
Village/Exodus Addiction Treatment Center, Miami, Fl. and University of
North Texas, Denton, Tx.
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In the residential treatment
of the chemically dependent a major clinical problem is retaining the
dependent person in treatment long enough to initiate the recovery
process. Following the abrupt discontinuation of high-dose chemical use,
the subject may experience lethargy, pain, dysphoria, and sleep
disturbances, culminating in anxiety and depression. Because of the
known calming effect of auriculotherapy (ear acupuncture) a randomized
study of auriculotherapy versus a capsule placebo group was
carried out in a residential setting among 66 residential patients. In
addition to the traditional Shen Men, Sympathetic, and Kidney
points, the Limbic system, Brain, and Zero points were incorporated in
the treatment of the acupuncture group. Completion rates were analyzed
by multivariate logistic regression. Patients who completed at least 10
days of auriculotherapy and did not receive intercurrent
medications were more likely to complete the 30 day residential program
than were patients in the comparison group (odds ratio =9.68, p=0.026).
This study suggested that non-medication based treatment could have a
positive effect on retention in a residential program. Based on these
results, a randomized, placebo controlled, single blind study utilizing
subluxation-based chiropractic care (Torque Release
Technique) was
implemented in the same residential setting. Three groups were
randomized: active treatment comprising daily adjustments to correct
vertebral subluxations using the Integrator adjusting instrument but set
to deliver zero force with no direction while maintaining the audible
click; and, a usual care group who followed the general policies of the
residential program. A total of 98 subjects (14 female and 84 male) were
enrolled after giving informed consent. The chiropractic and usual care
groups each had 33 subjects (5 females each) while the placebo group had
32 subjects (4 females). At baseline the Spielberger State Anxiety
scores were 50.0 + 1.9 for the Active group, 45.3 + 2.5 for the Placebo
group, and 42.8 + 2.0 for the Usual Care group. The Active and Usual
Care groups were significantly different at baseline (p<0.05). The
corresponding scores on the Beck's Depression Inventory were 18.6 + 1.6,
21.0 + 1.8, and 16.7 + 2.0 respectively. All of the Active group
completed the 28-day program, while only 24 (75%) of the Placebo group
and 19 (56%) of the Usual Care group completed 28 days. These completion
rates are significantly different than that for the Active group
(p<0.05). A Kaplan-Meier survival analysis showed that the
probability of retention in the Placebo and Usual Care groups was less
than that for the Active treatment group (Log Rank Test, p<0.001). At
four weeks the Spielberger State Anxiety scores were 32.0 + 1.6 for the
Active group, 42.5 + 3.0 for Placebo group, and 33.1 + 3.7 for the Usual
Care group. The Active and Placebo groups were significantly different
at four weeks (p<0.05), with the Active group showing a significant
decrease in anxiety (19.0 + 2.2, p<0.001) while the Placebo group
showed no decrease in anxiety (2.3 + 2.9, ns). The corresponding scores
on the Beck's Depression Inventory at four weeks were 2.6 + 0.7, 6.5 +
2.0, and 3.3 + 1.2 respectively. In contact to anxiety, the three groups
showed similar decreases in depression scores. The frequency of visits
to the Nurse's station was monitored during the courses of the study.
Among the Active treatment group only 9% made one or more visits to the
Nurse, while 56% of the Placebo groups (p<0.001 compared to Active)
and 48% (p<0.002 compared to Active) made such visits. In summary,
these modalities show significant promise for increasing retention of
patients in the residential setting.
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A "brain reward
cascade" of neurotransmitters, when operating properly, results in
feelings of well-being. If an imbalance impedes the normal flow of the
"cascade", the feelings of well-being are supplanted by anxiety,
anger,... or by craving substances which alleviate the negative emotions. Disruption
of the "brain reward cascade" results in Reward Deficiency
Syndrome ("RDS").
"RDS" can be manifested in mild forms (such as the chain smoker)
or more severe forms as in the chemical addict. A genetic based
biochemical inability to derive reward from everyday activity links these
extremes in behaviors. Alcohol addiction, obesity (as a result of
carbohydrate binging), nicotine addiction,
attention-deficit/hyperactivity disorder, cocaine addiction, Tourette's
disorder, and post-traumatic stress disorder are centrally mediated "RDS"
behaviors. Anomalies of the Dopamine D2
Receptor genes, Dopamine Transporter
genes, and Dopamine Beta hydroxylase genes predispose individuals to
"RDS".
Lack of dopamine receptors results in the inability to cope with stress
and causes craving. A number of substances (i.e., alcohol, cocaine,
marijuana, nicotine, carbohydrates) that release neuronal dopamine may be
taken in the attempt to gain temporary relief of stress and craving. These
substances can be used singly, in combination, or to some extent interchangeably
(have you noted how often recovering alcoholics crave
nicotine and/or sugar?).
In support of a comprehensive treatment regimen for "RDS"
behaviors, we must review research establishing the vertebral subluxation
complex as a primary issue in the multi-factorial expression of addictions
and compulsive disorders. The foundation of chiropractic is neurological;
therefore, for our purpose we re-focus on neurophysiology and
neuroimmunology.
The state of well-being has not received adequate scientific investigation
in chiropractic; nor has vertebral subluxation received due study
relative to its ability to interfere with the expression of both function
and communication "information". The "Brain Reward
Cascade" model is effective in providing a better understanding of
one's ability to maintain a state of well-being.
Feelings are mediated in the limbic system and are expressed through the
reward cascade of neurochemicals. A number of these neurochemicals
including neuropeptides are the biochemical mediators of a state of well
being. Using autoradiography science has established opiate receptors are
densest in the amygdala and hypothalamus (classically considered the core
of the limbic system). Pert and Dienstrey (1988) expanded the limbic
system (the neurosubstrate of emotions) to include the amygdala,
hypothalamus, dorsal roots and dorsal horn of the spinal cord. In this
regard a direct connection of the nocioceptive reflex at any level of the
spine to the limbic system has been established.
Moreover, we suggest it is time to accept that
"every level of the spine has an intimate relationship with the
limbic system's ability to process and establish a balanced brain reward
cascade" (Holder and Blum, 1995). A literature review (Holder and
Blum, 1995) revealed only vertebrates have an opiate receptor brain reward
cascade mechanism; therefore, inspite of opioid peptides found in
invertebrates, only vertebrates express a well-being state. In this
instance the common denominator is the spine and spinal cord. If the spine
is allowed to express itself without interference (minus subluxations),
the vertebrate can express a state of well-being at its greatest
potential. Consequently, the ability of the limbic system to function and
express itself without interference requires a subluxation free spine. In
1994 The Holder Research Institute finished a study implicating the
vertebral subluxation complex as a primary intervention resource in the
treatment of chemical dependency in a residential setting.
Pert and Dienstfrey (1988) state "The sub-conscious is in the spinal
cord and even lower" and :the sub-conscious extends to one's T-cells
[and] one's monocytes, and,... back to one's brain cells." The
origin of Pert's interference was at the dorsal horn of the spinal cord.
Burstein and Potrebic (1993), Harvard Medical School, provide evidence for
direct projection of spinal cord neurons to the amygdala and orbital
cortex. Their laminar distribution in the spinal cord and the involvement
of the amygdala and orbital cortex in limbic functions suggest these
pathways play a role in neuronal circuits that enable somatosensory
information, including pain, to effect autonomic, endocrine, and
behavioral functions. Giesler, et al. (1994), University of Minnesota,
found the spinal pathways to the limbic system for nocioceptive
information; they describe the pathway to include the hypothalamus
bilaterally. Prior to Giesler, et al. nocioceptive information was thought
to reach the hypothalamic neurons through indirect, multisynaptic
pathways.
Raffa et al. (1993), Robert Wood Johnson Pharmaceutical Research
Institute, report evidence linking the immune and opioid systems. Kyles et
al. (1993), University of Britol, found that when dopaminergic and opioid
systems process nocioceptive information it is mediated spinally.
Chiropractic must be maintained on a broad base, not limited to musculo-skeletal
applications. Further evidence supports the connection of a healthy spine
in mediating, not just immune system function, but growth factor,
chemotaxis of human tumor cells, body temperature, water saving and water
seeking behavior, etc. (Pert and Dienstfrey, 1988).
Similarities between the addictive process and subluxation are striking.
When one considers these similarities and the connection between the
subluxation complex and genetic deficits in the dopaminergic system, it
becomes important for the modern chiropractor to consider a total regimen
of natural healing including the maximum reduction of the subluxation
complex, genetic testing, and the administration of appropriate
neutraceuticals.
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