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Chinese Medicine Differentiation
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The role of acupuncture in the treatment of addiction has
traditionally been based on the use of acupuncture as if it
were a western treatment modality. While this approach
has made acupuncture more accessible as a research
modality, the subtlety and sensitivity of traditional Chinese
medicine has been lost. An examination of the traditional
Chinese etiologies associated with addiction and substance
abuse necessarily alters our understanding of the pathology
and therapeutics of addiction treatment.

To date, the literature examining the impact of acupuncture
on patients being treated for substance abuse and addiction-
related disorders has evaluated acupuncture as if it were an
occidental therapeutic modality. The purpose of this paper
is to re-examine substance abuse and addiction, and the
impact of acupuncture on addiction and addiction-related
disorders, from a viewpoint grounded in traditional Chinese
medicine theory. By re-examining addiction and treatment
from this viewpoint, we place the practice of acupuncture
squarely into the paradigm from which it evolved.

The literature on acupuncture and substance abuse has
fallen into one of three groups. The first group consists of
works discussing the impact of acupuncture on the treat-
ment of addiction (Kroening and Oleson, Clavel et al.,
Lipton et al., Wen and Cheung). The second group consists
of works that describe the physiological impact of acupunc-
ture on animals experimentally addicted to some addictive
substance, usually an opiate (Ng, Yang and Kwok, Tang
and Han, Fung et al., Wen et al.). The last group consists of
works that examine the physiological impact of acupunc-
ture on tests subjects (Wen et al., Kendall). In all of these
investigations, acupuncture is examined with respect to
outcome or mechanism of action from an occidental view-
point. While much of this work uses controlled studies,
such an experimental design is devoid of the principles
from which traditional Chinese medicine developed. What
is lost is the theoretical underpinning, and the diagnostic
and therapeutic subtlety of traditional Chinese medicine.

This failure to employ the principles of traditional Chinese
medicine stems from three causes. First, applying
acupuncture as a western modality has facilitated the role
of acupuncture as a research modality. Second, there has
been a movement in the acupuncture detox community
towards a simple “one size fits all” system for the treatment
of addiction. Third, there has been little attempt to evaluate
addiction in terms of traditional Chinese medicine.

Chinese Medicine Differentiation
Any examination of the theoretical basis of addiction and
substance abuse from the viewpoint of traditional Chinese
medicine must concern itself both with the overall
consequences of drug abuse, and the specific responses to
particular drugs. Regardless of which drug is abused, when
a substance is consumed at a level that produces significant
psychotropic effects, there is an inevitable change in the
shen or consciousness. Initially there is euphoria and
abnormal exhilaration, whilst continued abuse leads to
disturbances of the shen, dream disturbed sleep and
insomnia. Positive clinical findings at this stage include a
red tongue tip, and the pattern of disharmony corresponds
initially to an excess condition of the Heart, and eventually
to Heart fire.

Chronic abuse usually leads to a condition of tolerance
and dependence. Tolerance of a drug is the state where an
individual’s sensitivity to the drug’s effects is diminished,
and increasing amounts of the drug must be administered
to achieve the desired effects. Dependence is the condition
where a patient is psychologically compelled to use the
drug, or suffers outright symptoms of illness when the
abused drug is not administered. The experience of adverse
signs and symptoms following cessation of a drug of abuse,
termed withdrawal or abstinence syndrome, results from
being dependent on the abused substance for a state of well
being. When the substance is withdrawn, symptoms such
as anxiety, depression, difficulty in falling asleep and a wiry
pulse result. During acute withdrawal, the addict is experi-
encing symptoms of Liver qi stagnation.

During the initial phase of drug use, the drug user is



by Steve Given

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motivated by the desired alteration of the shen caused by
the drug being used. Once the addict becomes dependent
on the drug of abuse, they are trapped in a cycle of with-
drawal followed by self-medication after the onset of with-
drawal symptoms. In occidental physiological terms, the
individual experiences a drop in the blood and tissue con-
centration of the drug of abuse, leading to the development
of abstinence or withdrawal symptoms. When the addict
self-medicates, that is self-administers the drug of abuse,
the symptoms of withdrawal disappear and are replaced by
a sense of well being and euphoria. Of note here is that for
many drugs, the addict loses the ability to ‘get high’, that is
achieve a subjectively attractive alteration of the shen. They
use primarily or exclusively to avoid the symptoms of
withdrawal, i.e. they ‘use to get well.’

In terms of traditional Chinese medical theory, this cycle
of withdrawal and self-medication moves from Heart ex-
cess to Liver excess and back again. Using the addictive
substance leads to Heart fire. A drop in the blood level of the
addictive substance causes a shift to the Liver qi stagnation.

Some drugs, notably crack cocaine, produce euphoria only
initially. The addict spends the rest of her or his using career
attempting to replicate that first episode of euphoria or
‘high.’ In this case, the rapid build-up of tolerance shifts the
dynamic of the Heart to Liver oscillation in the direction of
Liver excess. The patient subjectively feels this shift in an
‘unscratchable itch’, that is a profound need to use that does
not return the patient to the remembered Heart excess
condition. This patient, unable to ‘get high,’ resorts to
bingeing behavior. Bingeing behavior, that is using a drug
constantly or nearly constantly for days or weeks at a time,
results in increases in both Heart and Liver excess: the shen
is agitated; withdrawal soon returns.

Whilst this shift occurs with all addictive drugs, there is
some individual variation. The abuse of the crack form of
cocaine and benzodiazepines such as Valium very rapidly
results in a shift from Heart excess to Liver excess. The
abuse of opiates results in a slower change. Regardless of
how fast or to what extent this change takes place, the goal

of the drug user profoundly changes. The role of the ‘strung
out’ or addicted drug user is increasingly the avoidance of
Liver qi stagnation. At the same time, the chronic insult to
the Heart leads to injury of the Heart qi. Heart qi deficiency
manifests with a pale face, shortness of breath, spontaneous
sweating, weak pulse, pale and flabby tongue and palpita-
tions. If the excessive sweating injures the yin, the result is
yin deficiency.

The cycle of Heart fire and Liver qi stagnation is further
differentiated according to the type of drug being abused.
Cocaine more strongly promotes the development of Liver
qi stagnation. Opiates such as heroin, methadone and mor-
phine, often result in shaoyang disharmonies, with chills
and fever. Opiates also strongly favor the development of
Liver-Spleen disharmony with anorexia, weight loss,
diarrhea and bloating, and Liver-Stomach disharmony re-
sulting in nausea and vomiting. While there is some varia-
tion in the development of such Liver, Spleen and Stomach
symptoms with different addictions, it is important to note
that these symptoms develop in all addicts to some extent,
and the variation between one drug and another is one of

The above patterns of disharmony involving Heart and
Liver excess, and Liver overacting on the Spleen and Stom-
ach, are the consequences of a cycle of drug use followed by
acute withdrawal. Chronic addiction, however, gives rise
to further disharmonies.

Chronic addiction, with its long-term Liver and Heart
heat, results in Kidney yin deficiency. Several factors exac-
erbate this yin deficiency. Sweating secondary to acute
opiate withdrawal and Heart qi deficiency damages the yin.
Diarrhea due to Spleen qi deficiency (as a consequence of
Liver-Spleen disharmony) also damages the yin. Yin defi-
ciency may be further exacerbated by fluid and blood loss
(e.g. from hemorrhage, childbirth, trauma or surgery) and
malnutrition. Malnutrition is an especially prominent cause
of deficiency for the addict because many addicts spend
available funds on drugs rather than food. Lastly, many
addicts are involved in excess sexual activity that damages
the Kidney yin. Kidney yin deficiency presents with night

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sweats, malar flush, tidal fevers, thirst, a red tongue with a
scanty yellow or geographic coat, and a rapid and thin
pulse. Kidney yin deficiency is also associated with low
back pain which is especially severe in cases of methadone
addiction and withdrawal (methadone is an addictive opi-
ate prescribed for heroin addiction). Kidney yin deficiency
occurs more frequently with opiate addiction than in addic-
tion to stimulants such as cocaine.

Deficiency of Kidney yin may result in Kidney yin failing to
nourish the Lung or Liver yin. In those patients with Liver
excess and Kidney yin deficiency, the deficient yin is no
longer able to control the yang, leading to Liver yang rising.
Symptoms include anxiety, red eyes, irritability, distending
headache, parietal or vertex headache, a wiry, thin and
rapid pulse, and signs and symptoms of yin deficiency such
as night sweats, malar flush, tidal fever, geographic tongue
coat and thin rapid pulse. In this case the yin deficiency is
both the result of a Liver heat pattern, and generates defi-
ciency heat of its own that further exacerbates the defi-
ciency and heat.

Liver yin deficiency is further exacerbated by the cycle of
withdrawal and self-medication. The longer the addict uses
an addictive drug, the more the chronic Liver and Heart
excess will lead to yin deficiency. The more deficient the
yin, the greater the Liver yang rising. This leads to a cycle of
positive reinforcement that results in greater and greater
Liver and Heart heat and increases severe yin deficiency.
The increasing disharmony leads to irritability, anxiety,
craving for the drug of abuse, and disturbance of the shen.
Clinically, the patient presents with a scorched tongue
without coat, malar flush, red eyes, severe night sweats and
excessive thirst. The pulse is wiry, thin and rapid. This
patient frequently ‘acts out,’ that is behaves in a potentially
destructive or hostile manner, impelled by Liver and Heart
excesses magnified by the yin deficiency. It is important to
note here that some patients have a propensity to Liver fire,
an excess condition that is in many ways similar to Liver

yang rising and which also leads to ‘acting out’ violent and
destructive behaviors. The important factor here is the
development of yin deficiency in the patient with Liver
yang rising.

Lung pathologies in the addict are primarily due to
deficiency, and are frequently associated with smoking the
addictive drug (see Table 1). Smoking crack (a smokable
form of cocaine) gives rise to Lung qi deficiency manifest-
ing as weak cough, weak voice, shortness of breath exacer-
bated by exertion, frequent colds and infections, a weak
pulse and a pale tongue. If the addict has developed yin
deficiency, the tongue may be red and geographic rather
than pale. Smoking tobacco gives rise to Lung yin defi-
ciency, resulting in an unproductive cough or a cough
producing scanty yellow phlegm, night sweats, a dry throat
and a hoarse voice. Severe Lung yin deficiency results in
hemoptysis. Where the patient is smoking heroin, the pri-
mary pattern of disharmony is one of phlegm heat in the
Lung. The patient presents with a productive cough, with
copious or thick yellow phlegm. Auscultation of the Lungs
reveals rhonchi and crackles. This hot phlegm may be
associated with Lung qi deficiency or Lung qi failing to
descend. The increased likelihood of phlegm production
with smoking heroin is due in part to injury to the Spleen
and consequent impairment of its ability to transport and
transform fluids. This leads to fluid accumulation in the
Lung, often in spite of the overall yin deficiency that is

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Chronic drug abuse may damage the Kidney yang as well
as the Kidney yin. Drug abuse resulting in chronic Kidney
yang deficiency leads to shortness of breath, with difficulty
on inhalation. This deficiency asthma pattern is especially
common in opiate abusers. Failure of Lung qi to descend in
heroin addicts is further complicated by the development
of Lung heat conditions in heroin or tobacco smokers. The
phlegm and heat block the Lung qi, which fails to descend.

When the addict is treated with drugs such as albuterol or
theophylline (bronchodilators used to treat asthma), these
medications act as strong stimulants resulting in increased
anxiety. This medication-related anxiety exacerbates the
Liver excess anxiety resulting from the addiction itself. The
addict is trapped in a self-perpetuating cycle of increasing
use, increasing symptomatology and further increases in

Injury to the Kidney yang also results in the loss of libido.
This loss, as with other patterns described above, is variable
depending on the drug being abused. It develops more
profoundly with the abuse of depressants, whilst with the
abuse of stimulants, especially methamphetamine, the yang
is preserved and in the initial stages there is a condition of
false yang excess resulting in hyper-sexuality. The abuse of
sex that results from the false yang increases yin deficiency
which further exacerbates the false yang. In some patient
populations, the addiction to and abuse of sex is a primary
motivation for the abuse of the drug in question, and these
individuals may be addicted to the false yang rather than
the Heart excess.

Cocaine’s ability to interfere with the brain’s
neurotransmitters, especially dopamine, alters the neuro-
chemical balance, leading to seizures. Stimulant use is also
associated with cerebro-vascular accidents. Spasm, syn-
cope and tremor are associated with interior Liver wind.
This wind follows Liver excess, especially where there is
heat or phlegm. Phlegm obstructs the Heart orifices, and
may be associated with a greasy tongue coat and a rattle in
the throat.

Clinical practice is based on the idea that pathology follows
etiology, and therapeutics follows pathology. If we can
differentiate etiology in substance abuse, then we imply
that there must be resulting differences in pathology, and
that even a patient population as superficially homogene-
ous on first observation as a substance abusing population
should benefit from differentiation in therapeutics. Current
clinical practice in the acupuncture detoxification field is
heavily based on the use of the same or nearly same protocol
for most or all patients presenting to a clinic for treatment of
substance abuse related symptomatology. This protocol,
consisting of the auricular points Shenmen, Sympathetic,
Liver, Kidney and Lung 2 (the lower auricular Lung point)
is designed to calm the shen, treat the Liver and Kidney, and
treat the vagus nerve (via Lung 2). This is an important
point prescription for three reasons. First, the point pre-

scription is very effective in calming the patient, and is an
effective means of treating the anxiety associated with drug
use and withdrawal. Second, the prescription clearly re-
duces drug craving for a variety of drugs, enabling the
addict to resist the urge to continue to use a substance, a
primary issue in addiction and recovery. Third, the pre-
scription supports the Liver and Kidneys and related organ
systems, reducing the signs and symptoms of drug use and

This protocol is promoted by the National Acupuncture
Detoxification Association (NADA), is described in litera-
ture on acupuncture and detoxification (Oleson,
Brumbaugh), and is the standard of practice in the acupunc-
ture detoxification community. Brumbaugh suggests that
at least in the early phase of treatment, the point prescrip-
tion should not be altered. It is necessary to question,
however, whether the addict is best being served by such a
limited armamentarium, or would efficacy be improved by
a differentiation based on the traditional Chinese medical
interpretation of the signs and symptoms? Clearly, an ap-
preciation of the subtlety of traditional Chinese medicine
suggests that some differentiation, even under the limited
conditions of a detoxification clinic, would improve effi-
cacy and clinical outcome.

Listed in Table 2 are the NADA protocol (referenced
above) and possible modifications of the NADA protocol.
While this point list is not exhaustive, clearly these points
can be used to develop a treatment model deriving from the
NADA protocol. These modifications could be the result of
pattern differentiation using the principles described pre-
viously. Table 3 shows additional auricular points that can

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be used to modify the basic auricular detoxification formu-
las in Table 2. They are chosen on the basis of the patient's
signs and symptoms. These additional auricular points
could also be selected based on whether they are sensitive
to palpation, or have a lower transdermal electrical resist-
ance than the surrounding auricular tissue, implying that
they are active and will therefore have a therapeutic impact.
These points are described by Oleson in his International
Handbook of Reflex Points.

The purpose of this article is not to question the undeniable
efficacy of acupuncture detoxification as it is currently
practised. The NADA based work has done a great deal to
lessen suffering and promote sobriety in the addiction
community. The questions rather are: i. what is the traditional
Chinese medical basis of addiction; ii. can we re-examine
the etiology, pathology and therapeutic basis for addiction
based on the principles of traditional Chinese medicine;
and iii. what could the impact of this re-examination be on
the therapeutic tools used by the acupuncturist in the
treatment of addiction?

Clearly, we have a firm basis for differentiating the addict
based on traditional Chinese medicine. While the above
discussion is by no means definitive, there is in it the
beginning of a differentiation based on the pattern of dis-

harmony. There is a strong correlation between the specific
drug of abuse and the array of patterns of disharmony
associated with the state of addiction. This differentiation
suggests some changes in therapeutics based on the pattern
of disharmony. Such differentiation and treatment modifi-
cation could be successful even in the limited treatment
setting of the detoxification clinic, with the patients sitting
in a communal treatment room fully clothed. It has been this
author’s experience that some of these modifications are
quite feasible (see Table 4). Where the pattern of dishar-
mony has determined a specific modification of treatment,
the efficacy of treatment has been enhanced by treating this
pattern, rather than simply directing the treatment at the
monolithic entity of addiction.

Blow, The Acupuncture Treatment of Alcohol and Chemical Depend-
ency, J.Chin.Med., No. 45, 1994.

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