NADA Protocol for Behavioral Health. Putting Tools in the Hands of Behavioral Health Providers: The Case for Auricular Detoxification Specialists

History and Background

The NADA protocol was developed in the mid-1970s at Lincoln Detox through a community process of experimentation and feedback [3]. From the research of Chinese neuro-surgeon, H.L. Wen, the Lincoln Detox group had learned about the effects of the ear lung point (with electrostimulation) in relieving acute opium withdrawal symptoms [4]. From there, the protocol developed into what is now known as the NADA protocol.

The people administering the NADA protocol at Lincoln Detox were a variety of frontline staff members—counselors, nurses, and peer recovery workers. Although formal acupuncture education was in its early stages, it was still not legal practice to have acupuncture needles inserted into the body by non-physicians [3]. The grassroots application of the NADA protocol at Lincoln even caused several brief closures of the program.

Considering the benefit that clients experienced with the ear acupuncture treatment, advocates formed the NADA organization in 1985 to facilitate its growth. In 1989, Lincoln Detox’s medical director, Michael O. Smith, helped petition for the first law in the United States allowing non-acupuncture personnel to provide this standardized and limited protocol. The new law stipulated that individuals could be Acupuncture Detoxification Specialists (ADSes) as long as they worked in a setting that also provided comprehensive addiction treatment services. It also required them to be supervised by a licensed acupuncturist or a physician with acupuncture training.

Lincoln Detox, renamed Lincoln Recovery Center in the early 1990s, became a thriving training center for ADSes, both from within and outside of the United States. The two-week training program was apprenticeship-based and would welcome a new group of trainees each week. By always having a group of trainees in the clinic room, Smith did not need to hire additional staff to provide the treatment. In this manner they were able to keep the training free of charge, and thus very accessible to many New York-based programs.

When those trainees returned to their programs, they provided the treatment as an addition to the existing array of services. Word spread about the innovative training and clinical services pioneered by Lincoln Recovery Center, through published research, congressional hearings, national conferences, and invited talks given by Michael Smith around the country. Gradually the practice of acudetox spread. The NADA organization estimates that some twenty-five thousand persons have been trained in this method worldwide [5].

The intervention is inexpensive and easily adopted especially when it can be provided by behavioral health treatment professionals either individually or within an integrated system of care. The practice of training behavioral health providers as ADSes is allowed by some but not all of the states in the U.S., and some but not all of the countries in the world [5]. To date there are twenty-one (21) states that have a statute giving a diverse group of healthcare workers the ability to be trained in the NADA protocol [6]. U.S. state laws vary in terms of who can perform the protocol, whether their scope is behavioral health or just addiction, where they can practice, and the kind of training, supervision, and oversight required.

The preponderance of clinical/anecdotal and evidence-based experience indicates that the NADA model of care improves treatment and health outcomes. The model includes the following components: (1) integration within other interventions; (2) barrier-free; (3) regular treatments; (4) a communal setting; and (5) local personnel and/or cross-trained health providers offer the therapy [7].

In 1993, according to a government survey of public and private substance abuse treatment facilities, there were 57 New York state programs reporting the use of acupuncture [8]. By 2000, that number had more than quadrupled, growing to 234. (The Substance Abuse, Mental Health Services Administration (SAMHSA) conducts an annual survey of addiction treatment programs and since 1992, that survey has included acupuncture amongst the “ancillary services”. Note that the survey question is about “acupuncture”, not auricular acupuncture or acudetox, and therefore does not distinguish the type of needling provided.).

One of these reporting sites was the SISTERS program—Sustained Interpersonal Strategies for Treatment and Empowerment of Recovering Substance Abusers—located within the Lincoln Recovery Center’s Maternal Substance Abuse Services (MSAS) [9]. A peer counseling model, SISTERS operated from 1991 until 1996 with grant funding from the Center for Substance Abuse Prevention. In addition to other services, SISTERS staff would administer daily NADA treatments until the client could provide ten consecutive days of negative urine toxicologies. Women who participated in the SISTERS program had babies born with higher birth weights as compared to the national birth weight average for babies born to women in recovery, and 78% of the babies were born with negative toxicology tests at the time of delivery. Program participants also had greater rates of family reunification with children either not living with them or in the foster care system.

The key takeaway from this program profile is that the services were run by peers who had themselves been successful graduates of the MSAS program. They coordinated services for SISTERS clients as well as provided the daily NADA acupuncture treatments. MSAS and the SISTERS program received national attention in the 1994 National Public Health and Hospital Institute publication, Vulnerable Women and Visionary Programs, which provided a review of programs that successfully helped drug-involved women and their children [10]. The publication notes that the effectiveness of peer counselors in improving outcomes was a key component.

A comparative study between two inpatient treatment programs, the Kent-Sussex Detoxification Center in Delaware which employed trained nurses as ADSes and an acudetox program at a Maryland hospital which hired acupuncturists, demonstrated a stark contrast in NADA service delivery. Study outcomes showed the use of ADSes in the Delaware program resulted in: (1) greater trust and rapport with clients; (2) treatment on demand—“with retention as the primary goal, the value of this service is inestimable”; (3) no additional cost to the program, save for the supplies—“Fees were incurred for consulting and the training of the nurses, but those fees were the equivalent of three weeks of acupuncture provided by licensed acupuncturists at the mental health hospital”, (4) administrative simplicity—“Organizing a group of acupuncturists and developing a schedule which takes time out of from their busy practices can be complex … only one face-to-face meeting with the five acupuncturists has been arranged in the six months”; (5) availability of acupuncturists—“Established acupuncturists are often unwilling or reluctant to interrupt their daily treatment schedules to travel fifteen to thirty minutes to a site where they earn considerably less”; (6) improved morale for the staff—“The improvement in the quality and efficacy of the program has come from internal resources”; and (7) staff become more potent agents for change—“The gift that acupuncturists can give to the field is the transfer of their knowledge and skills to those already working in the field [11] (pp. 11–12)”.

A Texas-based NADA trainer conducted a survey in 1996 to find out how willing and able full-body acupuncturists would be to provide their services, specifically the NADA protocol, in the public health sector [12]. The survey was administered to 233 licensed acupuncturists, and 60 expressed an interest. However, the majority of the interested acupuncturists had limited availability (one to two days per week) and expected to receive compensation. According to a program administrator quoted in the Guidepoints report at the time, “Our patients really look forward to the acupuncture and they are accustomed to having it available every day from their regular counselors. It doesn’t work well otherwise [12] (pp. 2–3)”.

A similar survey was administered to acupuncturists in Maine in 2017, although its scope was more general to public health, including addiction and mental health [13]. The survey results showed trends similar to the responses in the Texas study. A majority of acupuncturists responded that they did not want to join the new Maine Acupuncture Public Health and Wellness Committee to address the opioid epidemic in their state and would not be interested in volunteering either weekly, once a month or as a fill-in at one of four free acupuncture veterans clinics due to time constraints and travel distance. 53% responded that they offer pro bono acupuncture, but mostly out of their own clinic setting. Interestingly, 69% reported past experience working with clients and in programs treating addiction. However, most provided fairly limited timeframes that they could offer treatment to that demographic at present.

The west coast of the United States, primarily Oregon and California, have historically had many programs with hired acupuncturists providing the NADA protocol. A 2012 report revealed that due to budget cuts in the addiction treatment field, paid positions for acupuncturists in those states utilizing the NADA protocol sharply declined [14]. Neither of these states currently permits non-acupuncture ADSes.

While the research base for the NADA protocol has been mixed and does not include large scale replicated RCT trials, there is a growing body of positive small usual-care controlled studies and a large base of anecdotal reports [1]. One such study of NADA added to usual care in a residential substance abuse treatment program demonstrated statistically significant decreases in symptom severity [15]. Carter and his co-authors studied common symptoms associated with behavioral health disorders: mental/emotional (depression, anxiety, anger, concentration), and physical (cravings, decreased energy, and pain in the form of head and body aches). Two systematic reviews/meta-analysis studies address the benefits of auricular acupuncture and acupressure for pain [16,17]. The latter, which focused on emergency settings, includes studies of “battlefield acupuncture”, a standardized five-point protocol and style of auriculotherapy for treating acute pain widely adopted in military settings and applied by trained, non-acupuncturist, medical providers.

A Kaiser Permanente HMO-based study demonstrates not only benefits of adding NADA-style treatment to usual addiction care, but also the cost effectiveness. In their evaluation of 44 patients, those who received NADA supported treatment were more successful. Usual care with acudetox added was both more effective and less expensive to deliver [18]. Looking more deeply into the text, the authors show that the first year start-up costs were inflated by the necessary training fees which would not be required in subsequent years, indicating that the cost savings would be even more pronounced over time. Furthermore, the program was in California and the needling providers were licensed acupuncturists, not the agency’s clinical staff. Using ADSes (which California law does not currently support) would render the cost savings even more significant.

Treatment administrators have long known that even if they are not able to get direct reimbursement for the treatment itself, implementing the NADA protocol results in better outcomes, decreases clients leaving against advice, improves staff/client relationships and satisfaction, can be offered as staff wellness benefit, and improves marketing and competitive edge thereby paying for itself many times over.

While initially the NADA protocol was used as a supportive component in addiction treatment programs, after the 11 September 2001 attacks in New York City the protocol was discovered to be useful for people experiencing a severe traumatic event [19]. Its non-verbal nature helped people relax and sleep better which ultimately helped them feel better able to cope with the traumatic experience. The protocol was again used effectively in 2005 after hurricanes Katrina and Rita. That experience resulted in the passage of an ADS law in Louisiana—to increase access to this treatment tool for both addiction treatment and future disaster response capability. Another outgrowth of this NADA response was the founding of the nonprofit, Acupuncturists Without Borders [20]. This group now primarily relies on the NADA protocol to aid in disaster situations throughout the world.

When laws and conditions in a given state are supportive of ADS practice, the availability of the NADA protocol will increase. However, when the state law is not supportive of non-acupuncturist ADS practice, there is less provision of the NADA protocol and therefore less public benefit. We have described some historical evidence of that and present the current situation in the United States.

3.1. Three-State Survey

We emailed 740 surveys to all NADA-trained persons in the organization’s database, with the following response rate: California 33/295, 11.2%; Georgia 10/47, 21.3%; Colorado 92/398, 23.1%. The respondents reported on their knowledge of acudetox-using programs in their state as follows: California 34; Georgia 5; and Colorado 70.

See Figure 2.

3.2. Compilation of State-by-State Data

Using the SAMHSA data and information from each state regarding the number of licensed acupuncturists and ADSes, a state-by-state comparison was made including the number of licensed acupuncturists as reported by state-based regulatory authorities, the number of substance abuse treatment programs, the percent of treatment programs reporting the use of acupuncture and the number of ADSes with an active membership in NADA. States reporting the highest number of acupuncture services within substance abuse programs also have ADS-friendly laws. (By this ranking system, there are five states in category one, 19 in two, and 26 in three). See Table 1.

Comparing the results obtained from the survey of providers in the three representative states and the data obtained from SAMHSA there are some evident discrepancies. While the numbers for Georgia are consistent for both surveys—only five programs in that state and only 1.6% of the total programs report using acupuncture, practitioners in Colorado report more programs using acudetox, 70, than obtained in the SAMHSA survey, 39, which may reflect the broader inclusion in behavioral health and integrated health programs and not just substance abuse treatment programs. The discrepancy between the data for California—survey of NADA trained providers indicating 34 programs currently using acupuncture and the SAMHSA survey indicating 115 using acupuncture may be reflective of private programs utilizing full-body acupuncture, not just the NADA protocol. At the same time the 115 are only 8% of the total 1430 substance abuse treatment programs in California that report using acupuncture as an ancillary service.

3.3. Program Profiles Based on Personal Interviews

In Colorado, a law was passed in 2013 allowing for NADA training of licensed individuals in the behavioral health care field, including Licensed Clinical Social Worker (LCSW), Licensed Addiction Counselor (LAC), Licensed Professional Counselor (LPC), Licensed Marriage and Family Therapist (LMFT), Certified Addiction Counselor III (CAC III), and licensed psychologists. These professional groups were granted an allowance to utilize the NADA protocol in their respective practices without supervision, after successfully completing the NADA training (these clinicians have a license which allows them independence as mental health practitioners in the state of Colorado).

The NADA protocol is a safe procedure with minimal side effects [21]. The training includes clean needle technique and ADS providers have demonstrated knowledge and competence to continue to use this procedure safely and effectively without ongoing supervision. In the four years since the CO law has gone into effect, there has been a significant expansion of the availability of this treatment statewide. It is being implemented in private and publicly-funded substance abuse treatment programs, inpatient and outpatient mental health facilities, as well as fully integrated physical and behavioral health programs. Exposure to the NADA protocol has also increased the interest in acupuncture in general, with more people reporting an interest to the authors in pursuing full-body acupuncture with a licensed acupuncturist. This approach creates a win-win for all parties involved, patients, and providers.