Acupuncture  is a sophisticated system of energy medicine that is over  3000 years old. An external stimulus is applied to  specific energetically different points on the skin .  Neural and biochemical changes follow.

The origin of  acupuncture is unknown. Many scholars believe acupuncture  evolved during the Stone Age in Central Asia with the  Chinese being given the major credit, if not for the  original idea, at least for the development, practise and  preservation of acupuncture. (Dr M. Cohen presents a different view...)

References to acupuncture-like concepts exist in the ancient Egyptian Ebers papyrus  (1550 BC) and in ancient documents of India and Japan.  The "Shuo Wen Jie Zi" a Chinese book written  during the Han Dynasty (206 B.C-220 AD), makes mention of  pien (or, bian, according to another translation) meaning  "using stone to treat diseases".

The earliest  complete text on acupuncture is the "Huang Di Nei  Jing" (The Yellow Emperor's Classic of Internal  Medicine) written during the Warring States Period  (474-221 BC). This appears to be a compilation of all  acupuncture knowledge to that time and is still the basis  for modern acupuncture. The channels, 365 acupuncture  points, types of needles, use of moxibustion and  indications and contraindications were all discussed in  detail.

Sometime during this same time period the  "Nei Jing" was further enhanced by Pien  Chueh's "Nan Jing", in which the  "eight extraordinary channels" are documented.

Stone Age	Sharp Stones/bamboo slivers
1600 BC	Bronze needles
1500 BC	Egypt - Ebers papyrus
475 - 221 BC	China Nei Jing   Nan Jing   Nine types  of needles
206 B.C.-220AD	Hua Tuo - acupuncture  anaesthesia
265 - 420 AD	Zhen Jiu Jia Yi Jing Coloured diagrams & charts
562 AD	Japanese taught acupuncture
618 - 907 AD	Ah Shi points Imperial Medical College starts to teach  acupuncture
1027 AD	Weng Wei-yi casts life size "Bronze Men " as models with 657  acupuncture points
1683 AD	German, Dutch & French  teach acupuncture in Europe
1950	Japan - Ryodoraku
1950's	France - Nogier's  Auriculo- Therapy
1960's	Germany - Electroacupuncture  according to Voll
1965	Melzack & Wall - Gate  Theory
1976	Pomeranz - Endorphins

How Does Acupuncture Work?
Chinese and Western Views.
Dr Peter Davies MB,BS; DRCOG; DRACOG; M SC; Grad Dip Ed;
FACRRM 1999 History of (Chinese) Acupuncture

Crude forms of acupuncture seem to have been practised at various times in many parts of the world, but only in China did the technique attain the status of a major sophisticated form of therapy.

In China, stone needles dating back to 1700 BC have been found at an archaeological site in Anyan, in the Honan province. Even in China, however, acupuncture was never the only or even the main form of treatment; many more of the classical texts deal with herbalism than with acupuncture. But to understand traditional Chinese acupuncture one has to set it within the context of traditional Chinese medicine (TCM) as a whole, which in turn has to be set against the background of Chinese science and philosophy in general.

According to legend TCM commenced with Fu Hsi (c.2953) who is attributed with the invention of the eight Diagrams used as the basis of the I_Ching which acts as a pictorial representation of the Chinese universalistic philosophy. The elaboration of Chinese medicine was continued by the emperor Shen Nung (c. 2698) who is venerated as the father of agriculture and is reputed to have undertaken systematic empirical observation of all herbs by tasting each one in order to acquaint himself with their value. By far the most renown of the legendary rulers of ancient China however, was Huang Ti, also known as the Yellow Emperor who is said to have reigned from 2696_2598. Su_ma Ch'ien in the second century BC, began his Historical Records with an account of Huang Ti, whom he defined as the founder of Chinese civilisation and the first human ruler of the empire.

Huang Ti has been accredited with the invention of wheeled vehicles, armour, ships, pottery, and other useful appliances, as well as the art of writing.

Huang Ti is also regarded as the author of the Canon of Internal Medicine called the Nei Ching Su Wen (The Yellow Emperors Classic of Internal Medicine) which is said to be the oldest extant medical book in the world.

This text remains the theoretical foundation for Chinese medicine to this day, as Ilza Veith states in the introduction to her translation of the Nei Ching; The Nei Ching, the Classic of Internal Medicine, attributed to Huang Ti, the Yellow Emperor, is ... the most important early Chinese medical book...

It is important because it develops in a lucid way a theory of man in health and disease and a theory of medicine. It does this in very much the same way as did the physicians of India who wrote the classic books of Yajutvedic medicine, or the Hippocratic physicians of Greece; that is by using the philosophical concepts of the time and picturing man as a microcosm that reflects the macrocosm of the universe.

The theory expounded in the Nei Ching Su Wen has remained the dominating theory of Chinese medicine.

Despite the authorship of the Nei Ching Su Wen being attributed to the Huang Ti, its antiquity has been questioned and most historians now date its origins to around the fourth century BC at the earliest. It was around this time that the foundations of Eastern and Western medicine were being forged, with the formation of the Hippocratic writings in the West, and the canonization of the Nei Ching Su Wen in the East. (These medical works are significant as they mark the beginnings of modern medicine and are the first treatise to view disease as arising from interactions between the environment and constitutional factors, rather than the actions of gods or supernatural forces.)

Later writers commented on the Nei Ching to bring out and clarify its ideas and sometimes to add new ones. Without such commentaries the Nei Ching would be almost incomprehensible to modern readers.

Modern Chinese textbooks are based on works written in the Ching (Manchu) period (1644_1911) and before that on the Han period (202 BC to 220 AD). Much of traditional acupuncture as understood today, therefore, is not of vast antiquity but dates from the Ching (Manchu) Period.

The Nei Ching Su Wen, is unusual for a general medical text in that it is devoted primarily to preventative measures. Rather than defining different disease entities and attempting to treat illness, the ancient Chinese physicians emphasised the healthy state which was defined as being 'at one with the Tao', and having defined a state of health, it was the aim of Chinese physicians to detect any deviation from this state and correct it before disease could develop. Placing great emphasis on the pulse, Chinese physicians aimed to detect premorbid conditions before they developed into overt pathology, and since disease was seen to arise out of disequilibrium, the basis of cure was in restoring harmony.

The duty of the traditional Chinese doctor was to instruct the patient how to remain well and accordingly, the ancient physicians were paid only while their patients remained healthy. This is in stark contrast to that of the Hippocratic tradition. The Hippocratic physicians were sought only after disease had become established and a physician's worth was judged on his ability to make accurate predictions, even if powerless to alter an adverse outlook. The Hippocratic tradition thus concentrated on defining specific disease entities rather than abstract notions of health, for it was only by defining the evolution of clinical syndromes that specific prognostic features could be recognised and the likely course of disease and the effect of specific interventions be determined.

Although acupuncture and herbal therapy have always been part of TCM; acupuncture (but not herbal therapy) has rapidly evolved rapidly in the last fifty years. Laser, electrical stimulation, auriculotherapy and myofascial trigger point therapy are some of the recent variations on the acupuncture theme.

The basic concepts of traditional Chinese medicine Yin and Yang Yin_yang polarity is at the core of Traditional Chinese Medicine (TCM).

The terms yin and yang are impossible to translate. Originally yang meant the sunny side of a slope or the north bank of a river, while yin meant the shady side of a slope or the south bank of a river. These meanings were later extended to cover a vast range of polarities, so that, for example, yang came to refer to heat, movement, vigour, increase and upward or outward movement, while yin referred to cold, rest, passivity, decrease, and inward and downward movement.

On the biological level yang is male, yin female. It is essential to realize that although yin and yang are polar opposites they are not mutually exclusive. Yin always contains at least a trace of yang and vice versa. In the traditional yin_yang diagram this is indicated by the fact that yang contains a small spot of yin and yin a small spot of yang.

Perhaps the nearest Western equivalents would be the concepts of positive and negative in electricity and north and south in magnetism. But yin and yang are not thought of as static fixed entities; they constantly interact with each other and transform themselves into each other. In the whole of nature, as well as in ourselves, there is an ever_changing flow of yang into yin and yin into yang.

Our state of health is thought to depend on the balance between yin and yang. If either preponderates more than it should the result may be disease, which is thus thought of as resulting from a dynamic imbalance. Treatment is conceived of as a means of restoring the balance, and classical acupuncture is wholly concerned with this. Chi Another untranslatable term. It is sometimes rendered as energy, but Chinese thought does not distinguish between matter and energy, partly because classical Chinese thought doesn't seem to go in for definitions much.

The ancient Chinese preferred to describe things in terms of what they do rather than what they are. Thus chi sustains all kinds of movement and change, it protects against harmful influences, it transforms food into other substances as well as into chi itself, it holds organs in place and prevents excessive fluid loss, and it warms the body. It flows in the blood vessels and also in special channels (meridians), in conjunction with the blood. (Chi is yang, blood is yin.)

The Organs. TCM recognizes many of the organs familiar to us, but as usual they are thought of dynamically, the reference being to the organs' supposed functions as much as to their structures. There are six yang organs (gall bladder, stomach, small intestine, large intestine, urinary bladder and triple warmer). There are five yin organs (heart, lungs, spleen, liver and kidneys); the pericardium is sometimes included as well to bring the number to six. (The triple warmer corresponds roughly to the centre of the body: abdomen and mediastinum.)

The Channels and Points. The term meridian, though widely used, is misleading; 'channel' is a better translation of the Chinese term (ching), since the idea is that there are subtle vessels running throughout the body to connect the organs and carry chi. Diagrams of the channels represent them as if they were lying on the surface of the body, but in fact they are to be thought of as running at a variable depth inside the body and only coming the surface at certain places. (They have been compared to an Underground Railway.) The acupuncture points mostly lie on the channels at places where they run near the surface. A few points (the so_called extra_meridian points) do not lie on channels. Some 360_odd acupuncture points are described, but in practice a much smaller number are used. The points all have Chinese names which often sound poetic in translation (Sea of Blood, Gate of Dumbness, Crooked Spring) but Western acupuncture books use a more prosaic system of numbering, which is more or less standardized.

The Five Element Theory. This is complementary to the yin_yang idea. It usually attracts a lot of attention in Western books on TCM, perhaps because it is complicated and allows plenty of opportunity for mystification. Modern Chinese books on TCM, at least in Western languages, usually say little or nothing about it. `Elements' is a misleading translation of the Chinese term, which as usual has a dynamic implication. 'Five phases' would be better, because the so_called elements change into one another. Their names are Wood, Fire, Earth, Metal and Water, and they are related to the various organs and to one another in a complicated manner. The interplay of the phases or elements has implications for treatment in the traditional system.

Disease causation in TCM. Disease is held to be produced by three kinds of influence: environment, emotions, and way of life. Environmental influences are wind, cold, heat and dampness; way of life includes diet, physical activity and sexual activity. The modern concepts of altered physiology and pathology do not enter into the picture. It is therefore difficult to make a correspondence between TCM and modern views of disease, and this bedevils attempts to interpret TCM in the modern context.

Methods of diagnosis. The traditional Chinese physician, like his Western counterpart, takes a history and notes the patient's general appearance and demeanour. Particular attention is paid to the tongue: its colour, coating and so on.

The most important examination, however, is that of the pulse. This is felt at the wrist at three locations on each side and both superficially and deeply, giving a total of 12 pulses which are related to the 12 internal organs. (Some sources give even larger numbers of pulses.) The quality of the pulse is described in terms such as slippery, rough, and wiry. A skilful physician is said to be able to derive an astonishing amount of information from the pulse alone, but learning the art requires thorough training, long experience, and the gift of intuition or sensitivity.

The information it provides is of course couched in terms of TCM, and it is difficult or impossible to translate these into modern concepts.

Treatment according to the traditional system. This may be herbal or acupuncture (or both). In the case of acupuncture, the physician will check the patient's pulses and decide which organs are out of balance. Needles are then inserted to 'stimulate' or 'sedate' the relevant organs by adjusting the flow of chi. This is essentially a hydraulic concept; the acupuncturist is thought of as a kind of engineer,ng and closing the valves as appropriate. In most cases a number of needles are inserted and left in for 20 minutes or so. Much emphasis is laid on the accurate placement of the needles.

A great deal of attention is paid to obtaining various types of sensations from the patient and the physician also experiences various sensations as he manipulates the needle. These phenomena, which are collectively called the chi, are supposed to be due to tapping into the flow of chi.

Four typical sensations are described, and their names have been translated as numbness, fullness, heaviness and sourness (a kind of muscular ache like that caused by over-exertion).

Traditional acupuncture is clearly a time-consuming business and it is hardly surprising that in modern Chinese hospitals, with their huge numbers of patients, the full system doesn't seem to be used very much. Instead, the patients are treated collectively in large groups, purely on the basis of their symptoms or of a conventional medical diagnosis, without the use of pulse diagnosis or the other traditional procedures. As a rule many needles are inserted and electrical stimulation may be used.

The ancient Chinese were remarkably pragmatic thinkers, and their modern descendants are certainly very receptive to new ideas in acupuncture; they have indeed introduced a number of innovations of their own. Certainly they are in no way hostile to studying acupuncture scientifically or to trying to explain it in modern physiological terms. They show, in fact, a notable degree of flexibility in their thinking, which is often not matched by Western advocates of traditional Chinese medicine. Western enthusiasts for traditional acupuncture often cling tenaciously to the ancient theories and practices and make a point of emphasizing how different acupuncture is from conventional Western medicine.

As often happens with other forms of alternative medicine, acupuncture often becomes for such enthusiasts more than a mere method of treatment; it takes on a mystical aura, even though this was not a feature of the traditional system.

Modern Acupuncture Acupuncture has been known in the West since the second half of the seventeenth century, and interest in it has waxed and waned since then.

The modern revival of interest dates from President Nixon's visit to China in 1972.

Much excitement was generated by claims that it was possible to carry out major surgery using acupuncture as the sole analgesic. At about the same time, the discovery of the opioid peptides appeared to provide a physiological basis for acupuncture and this helped to make it more scientifically respectable.

Another shaft of illumination came from the gate theory of pain put forward by R. Melzack and P.D. Wall. The neurophysiological basis of acupuncture is now well established on the basis of endorphin and other neurotransmitter involvement, the diffuse noxious inhibitory control system (DNIC) and the gate control theory.

The reality of acupuncture points however is often questioned for no consistent structural correlates for them have been identified.

Acupuncture points it seems are best considered as functional, rather than structural entities, and this is confirmed by the finding that acupuncture points can be defined electrically as points of low electrical resistance. The functional nature of acupuncture points is also evident from the fact that there is an extremely high correlation between acupuncture points and musculoskeletal trigger points, which are points of focal muscle tenderness that can be identified using a pressure algometer or palpation, and which are found to have a local twitch response to mechanical stimulation.

While functional correlates of acupuncture points have been shown to exist, sceptics often point out that the acupuncture meridians have not been objectively identified.

Most acupuncturists however would maintain that acupuncture meridians are a conceptual tool, such as the lines of latitude and longitude on the earth, and thus while they are useful for navigating a specific territory, to search for anatomical correlates of the meridians would make as much sense as digging in the ground to look for the equator.

Recently however there has been the suggestion of objectively defining the meridians using techniques capable of imaging functional, rather than structural relationships.

Studies utilising radioactive tracers have shown that certain tracers appear to migrate along the acupuncture meridians and electrical impedance studies have shown significantly lower impedance along the acupuncture meridians compared to surrounding skin. It is generally acknowledged amongst practitioners that the main mode of action of acupuncture is through stimulating homeostasis. This no doubt involves neuronally and chemically mediated phenomena, however while the neurophysiological basis for acupuncture is well established, acupuncture has also been shown to decrease red blood cell viscosity, white cell count, carotid arterial pressure and peripheral vascular resistance, increase free fatty acids, gamma and beta globulin levels, the phagocytic index of white blood cells and the blood glucose level as well as enhancing the release of serotonin, histamine and kinin components.

Acupuncture also affects the autonomic nervous system and skin temperature as well as electroencephalograph, electrocardiograph and electromyograph readings. Furthermore acupuncture has also been shown to produces multiple effects on defence and immune mechanisms including raising the titre of a variety of specific and nonspecific immune substances such as bacteriolysins, agglutinins, opsonins, antibodies and complement components.

While the above findings are indeed significant, these findings merely take the form of evidence of how acupuncture may act through the actions of particular nerve pathways and central mechanisms or through the release of humoral agents and although this evidence suggests how acupuncture works, it does not explain why acupuncture works.

The opioid peptides. There are three families of opioid peptides: the endorphins, the enkephalins, and the dynorphins. There are also at least three kinds of receptors. The opioid peptides are widespread throughout the body and probably have a role not only in pain perception but also in other sensory pathways and also in autonomic and motor control. They may affect the immune system, though this is not yet established. Acupuncture has been shown to increase levels of some if not all opioid peptides.

The gate theory. According to the old model of pain perception, which goes back as far as Descartes for its ultimate inspiration, the nervous system is something like a telephone system. If you tread on a drawing pin, say, a pain impulse travels up the nerves from your foot to your spinal cord and thence to your brain, where in some wholly mysterious way it gives rise to a pain in consciousness. This model is a passive one, in that transmission of the painful stimulus is supposed to happen automatically provided the nervous pathways are intact. Melzack and Wall (1992) have pointed out that there are serious difficulties with this scheme.

Sometimes a severe injury causes little pain, or a relatively trivial injury may cause agonizing pain. Again, pain may persist for months or years after the original injury has healed completely. The new model proposed by Melzack and Wall is based on the idea that the brain does not just attend to single messages coming along specific nerve fibres but instead monitors all the information at its disposal before registering pain.

This is the basis of the 'gate theory'. To describe this in the sketchiest possible outline, the spinal cord and brain stem is supposed to contain 'gates' which canor close to allow pain impulses to travel to the brain or not, as the case may be. Afferent impulses from the periphery canor close the gates, according to the type of nerve fibre involved: large diameter fibres close the gates, small diameter fibresthem. This explains why rubbing the site of an injury can relieve pain. The gates are also supposed to be influenced by efferent or descending impulses from higher centres in the brain, including those concerned with consciousness. This helps to explain how psychological factors alter our perception of pain and why patients who are afraid of acupuncture or unwilling to have it seldom do well. Melzack has himself applied these ideas to acupuncture.

One difficulty with such theories is to explain how the brief insertion of a needle can cause pain relief lasting for days, weeks, or even permanently. One suggestion is that the nervous system is continually bombarded by impulses arising from the persisting microtrauma inflicted by the needle; another is that the initially temporary relief of pain allows the patient to use the part more freely and hence to provide a more normal input of impulses into the central nervous system.

Repeated acupuncture would enhance this effect and so set up a 'virtuous circle' of progressive relief of pain. Whether the gate theory is correct in detail or not is not critically important for the working acupuncturist. What matters is the idea of the nervous system as a dynamic, constantly changing and evolving interplay of patterns, in which it is not surprising to find that altering the input by inserting needles can produce quite profound alterations in function. The following diagram indicates some of the factors involved.(Diagram?)

The opioid peptides and the gate theory, though of importance as providing a theoretical underpinning for acupuncture, don't have a great deal of relevance to everyday practice. There are however two other ideas which do have a great deal of practical relevance: pain memory and trigger points points (TPs).

The concept of pain memory 'Memory' in this context does not refer to the conscious recollection of painful events, but to the persistence of functional and possibly structural changes in the central nervous system as a result of injury to distant parts of the body. To most patients, and many doctors, to suggest that pain can persist without a 'cause' in the ordinary sense of the word appears absurd. We are all familiar with the pain that arises from an acute injury, and it is natural to assume that when pain persists it must be because of some continuing lesion at the site of injury. But there are plenty of examples to the contrary: central (thalamic) pain and phantom limb pain, for example. It might seem that pain of this kind is a fortunately rare phenomenon. But conceivably it is really very common. It may be that many kinds of chronic pain, even most, are due to persisting changes within the nervous system. It is not possible to say exactly what these changes are, though it has been suggested that they may be reverberating neuronal circuits. There could also be biochemical changes at the cellular level.

Those of us who are not experts in the field may be satisfied with a grossly over-simplified picture, and think in terms of analogies such as the loops that may occur in a computer program or even the eddies in a stream. Trigger points and acupuncture Trigger points (TPs) are zones in muscles and sometimes in other tissues that are tender when pressed and which may give rise to referred pain and other remote effects.

The earliest recorded research on the referral of muscle pain was carried out by Kellgren, following up the chance observation by Sir Thomas Lewis; his technique involved injecting 6% saline into various sites in volunteers and recording the pain felt. He found that injecting tendons or tough connective tissue produced local pain, whereas injecting muscle bellies produced pain referred in a constant pattern some distance away from the site of injection.

The most complete study of TPs has been made by J.G. Travell and D.G. Simons. Travell, an orthodox pain specialist in the USA who looked after President Kennedy, published a classic paper on the subject in 1992. She later collaborated with Simons in their major work on the subject, Myofascial Pain and Dysfunction: the Trigger Point Manual.

Melzack studied the relation between TPs and acupuncture points. He and his colleagues found that every TP recorded in the Western literature has a corresponding acupuncture point, and in 71 per cent of cases there was a close relationship between the patterns of pain associated with the two kinds of point. TPs are a clinical phenomenon and little hard evidence exists to show what they actually are. Attempts to excise them for histological examination have generally been unsuccessful, partly because - at least at an early stage - they are very transient.

There have been claims that they are localized areas of muscle spasm, or alternatively that they are localized areas of inflammation produced by theng of small arteriovenous shunts. It is also possible that the changes in the muscle are not really the primary event, but are secondary to altered patterns of function within the CNS.

Clinically, TPs may be latent TPs or active .An active TPs TP gives rise to referred pain and sometimes to other remote effects such as muscular weakness or autonomic changes. TPs can also be classified as primary TPs and secondary TPs (found in areas of referred pain). Satellite TPs TPs occur in synergist or antagonist muscles. TPs have been described under many other names (fibrositis, fibromyalgia, muscular rheumatism). They underlie many kinds of clinical problems. They appear to become active for many reasons: overuse, fatigue, chilling, maintenance of faulty posture, for example; the currently fashionable 'repetitive strain injury' is a classic example of a TP disorder. Once established, they may persist for many months or even indefinitely.

Two common patterns of origin are seen. A sudden overload may cause a TP to develop in a muscle: for example, after digging the garden in spring. Alternatively, long-standing misuse of muscles, for example by faulty posture, may activate the TPs. An initial primary TP may give rise to secondary TPs, usually in a distal distribution.

Dr Chann Gunn has proposed that partial denervation of a muscle, such as may occur in radiculopathy, causes hypersensitivity of the muscle concerned and consequent development of TPs.

TPs are detected by means of palpation. The main technique consists in drawing the finger transversely across the muscle, or alternatively (for "strap" muscles such as the sternomastoid) by grasping the muscle between finger and thumb. Resistance may be felt in the muscle fibres, and the patient will experience pain, which can be quite severe (the 'jump' sign). A muscular twitch may occur, and there may be radiation of pain to the areas of referred pain. In general, referral of pain appears to occur from proximal to distal and from behind forwards.

Learning to locate TPs is a very important part of acquiring skill in acupuncture. Common sites for TPs are near the muscle attachment to tendon or bone, central within the belly, or at free borders. Because the TP may be very sensitive, examination must be done gently. It is important to compare the two sides of the body because it is increases in tenderness that are significant.

TPs can be inactivated in various ways, including simple pressure ('acupressure') and acupuncture, as well as by injecting various substances (local anaesthetics, corticosteroids, or even saline).

A great deal of modern acupuncture (perhaps 80 per cent) can be thought of as the detection and inactivation of TPs. Auriculotherapy (Ear acupuncture, EA). Ear Acupuncture (EA) is not a part of traditional Chinese medicine. It was pioneered by Dr Paul Nogier in 1956. Most of the initial work was done in Lyon in France. Almost all of the currently used ear points have been discovered since 1970, and although EA is one of the most researched of the "micro-system"acupuncture systems, we still know little about how and why it works, or how to best us the system.

Nogier's original description of auriculotherapy point location was to imagine the picture of an upside down foetus superimposed on the ear. That is being replaced by illustration like that opposite,(Diagram?) which bears considerable resemblance to the diagrammatic representation of the role of different areas of the cerebellum that were popular in physiology texts in the 1960's.

While these illustrations may be of value in point location, they are of little value explaining how acupuncture works.

The auricle has a complex, multiple sensory sympathetic and parasympathetic innervation, involving both cranial and cervical nerves.

Trigeminal Nerve (V cranial)
Facial Nerve (VII cranial)
Vagus nerve (XII cranial)
Glossopharyngeal nerve (X1) (ear canal and variable part of pina in some people)
The greater auricular nerve C2 & C3
The lesser occipital nerve C2 , C3 & (sometimes) C4

The mechanism of action of auriculotherapy is unclear, but presumably is related to the central connections of the cranial and cervical nerves. By stimulating areas of the auricle innervated by different nerves, different result are obtained. Unfortunately, this was not appreciated by many early researchers, who did not always record what part if the ear they were stimulating.

This may account for many of the differing results obtained by apparently similar techniques. It also appears possible to obtain different effects with different point combinations.

There are several (sometimes conflicting) main theories for how auriculotherapy works in drug withdrawal (my main area of interest in auriculotherapy.)
1). Serverson, Markoff & Chun Hoon suggested that auriculotherapy might be due to parasympathetic inhibition via the vagus. They sited the following as supportive evidence. Parasympathetically mediated symptoms such as lachrymation, rhinorrhoea, chills, sweating, intestinal cramps, and bowel hyperactivity are the first to respond, with anxiety and heroin craving next, joint and bone pain last and often incompletely.
2). Conversely, Mendelsson suggested that the symptomatology of narcotic withdrawal was due to an imbalance of adrenergic and cholinergic neurotransmitter systems, with a central adrenergic predomination. Therefore, to work, the effect of auriculotherapy must be parasympathetic stimulation. Centrally active cholinesterase inhibitors are effective in reducing opiate withdrawal symptoms due to augmentation of central cholinergic activity. B-adrenergic blockers such as propanolol diminish sympathetic activity, which, by implication, supports the belief that auriculotherapy may work by para-sympathetic activation via the vagus nerve.
3). Chen suggested that auriculotherapy may simply substitute endogenous endorphins for exogenously administered opioids. Low frequency electrical stimulation auriculotherapy causes elevation in CSF levels of B-endorphins (whose effect is blocked by naloxone) but no elevation in met-enkephalin; while high frequency electrical stimulation auriculotherapy shows elevations in CSF met-enkephalin, whose effect is not blocked by naloxone. (This may be why rapid detox using naloxone AND high frequency electrical stimulation auriculotherapy is effective.)
4). The efficacy of clonidine (a central noradrenergic inhibitor) in treating symptoms suggests that noradrenergic activity is common in withdrawal states. Glassman et al suggested a special relationship between noradrenergic activity and craving. (Which may be why stress increases craving. Stress increases central noradrenergic activity hence the urge to eat or drink alcohol or smoke or shoot up - whatever the individual uses to relieve stress. This is a powerful conditioning that could rapidly lead to habituation.)

The locus caeruleus is in the floor of the forth ventricle on the posterior surface of the medulla oblongata. It has large numbers of noradrenergic neurons and high concentrations of opioid receptors. It is postulated to play a critical role in feelings of alarm, panic, fear and anxiety, and contributes the main noradrenergic input to the brain.

The noradrenergic outflow is considerably increased in opioid withdrawal, which presumably causes much of the concomitant distress. Activity in the locus caeruleus is inhibited by V-adrenergic agonists (such as clonidine), and by both exogenous opioids and endogenous opioid-like peptides. Auriculotherapy might stimulate endogenous opioid release here and at other relevant sites. Whatever the mechanism of acupuncture, it is generally accepted that acupuncture alone is not effective in the long term treatment of drug addiction. It has a useful role in both alleviating the symptoms of withdrawal, and in encouraging group therapy in the NADA based programs. It is the long term psycho-social therapy that is the major factor in predicting success.

Acknowledgement: Much of this article was based on the writings of Andrew Campbell and Marc Cohen.

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