Acudetox Evaluation at HMP Wetherby

By 26th June 2016Featured, Reports
Acudetox Evaluation chart

An Evaluation of Auricular Acupuncture on the Keppel Unit

By Dawn Townend (2014)

Executive Summary

This current report has built on the previous findings and looks specifically at the thirty seven self-completion evaluations by young people who finished a programme of auricular acupuncture between the 1st January 2013 and the 30th April 2014. Each six-week programme consisted of weekly sessions lasting up to forty-five minutes.

Factor Improvement
1 Anxiety 84%
2 Cravings for drugs 83%
3 Depression 77%
4 Anger 72%
5 Cravings for alcohol 71%
6 Concentration 69%
7 Sleep 65%
8 Relationships 57%
9 Energy 52%
10 Pain 50%
11 Appetite 40%
12 Self esteem 40%
13 Confidence 35%

The first 5 factors all demonstrate an improvement of over 70% and are arguably the factors that have the largest impact on behaviour management within the Prison.

A reduction in anger, anxiety and depression could play a role in reducing incidents of self-harm and could reduce the episodes of overt displays of anger and aggression that sometimes lead to either violent behaviour towards others or self-harm. There is clearly an opportunity for further research to examine these suppositions in relation to the contribution that acupuncture makes to the overall stability of the unit and the therapeutic environment.

An Evaluation of Auricular Acupuncture on the Keppel Unit

Introduction

Auricular acupuncture

Auricular acupuncture involves the insertion of fine needles into the ear. The National Acupuncture Detoxification Association (NADA) protocol for five-point auricular acupuncture centres on the following points; the Shen Men, Sympathetic, Kidney, Liver and Upper Lung nadauk.com Initially this protocol focused on supporting the recovery of those with substance misuse problems by reducing cravings, reducing withdrawal symptoms, improving sleep, facilitating relaxation and increasing a sense of well-being. However in more recent times the protocol has expanded and the benefits of the treatment include: relaxation for young people with behavioural disorders, stress and anxiety management and smoking cessation. These problems are particularly prevalent in young offenders and research has show that a significant number of young people in custody experience some kind of mental health problem or behaviour disorder (Chitsabesan et al 2006). Furthermore contemporary studies have identified that young peoples’ mental health and well-being is adversely affected through the increase use of technology, ‘screen time’ in addition to the existing challenges of adolescence (Etchelles 2013). When young people in custody are locked in their cells, watching television and playing on a games console are often favoured as in-cell activities. It is suggested that young people should therefore be encouraged to participate in healthy behaviour. This report suggests that the participation in auricular acupuncture should be considered as a healthy behaviour.

Auricular acupuncture has been used in Chinese medicine for over 3000 years, yet it is argued there is a weak evidence base to demonstrate the effectiveness of the treatment in treating alcohol and drug dependency (NICE 2008); although the National Institute for Health and Care Excellence (NICE) do acknowledge that there is anecdotal evidence provided by service users that acupuncture is valued (2011). The reported lack of evidence is synonymous with the lack of empirical research that is available. Whilst the origins of acupuncture are in the East much of the research that has been subjected to criticism, due to poor methodological quality and lack of control of possible extraneous variables has been conducted in the West, predominantly in the US. It is questionable as to whether auricular acupuncture should be subject to the same scientific rigour as other clinical treatments, when it arguably does not sit within the same paradigm. Perhaps a move away from positivism and empiricism is required in order to observe and interpret the benefits of this treatment.

Further research has attempted to dispute the effectiveness of the treatment in relation to drug dependency. Jordan (2006) reported there was no evidence to support the use of acupuncture as a stand-alone treatment for opioid dependence (Cited in NICE 2008). However recovery does not rely on a single treatment but an integrated plan of support and care. Even with the prominence of the Medical model and the Psychosocial approach in supporting the recovery of those with substance use problems in the UK, the use of regulated alternative therapies has continued to grow. A study conducted in the UK reported that 93% of GPs and 70% of hospital doctors had at least on one occasion suggested a referral to alternative treatment (Perkin et al 1994). Auricular acupuncture is a comparatively inexpensive treatment that runs concurrently with other therapies and interventions. Wang et al (2001) concur that acupuncture has become increasingly popular in Western medicine even with the slow progression of scientific evidence.

Acupuncture on the Keppel Unit

The Keppel Unit accommodates and supports vulnerable young males in the juvenile custodial estate who are aged 15-18 years old. The young people on the unit have a variety of complex needs, the preponderance (over 95%) reporting some kind of substance use prior to custody. The auricular acupuncture programme is well established and is delivered as part of an integrated care planning approach, tailored to meet individual needs. At any given time approximately a quarter of the young people on the unit are completing a programme of acupuncture. There are two substance misuse practitioners who have been specially trained by NADA to provide five-point auricular acupuncture to the young people on the Keppel Unit. The substance misuse practitioners also provide a range of psychosocial interventions that run concurrently with the acupuncture programme, it is not used as stand alone treatment. Furthermore it is available to all young people on the unit and not limited to those with a previous drug dependency. The NADA protocol identifies that the combined application of acupuncture and other interventions enhances the effectiveness of the treatment www.nadauk.com/node/9. This is evidenced in research conducted by Bier et al (2002), who found that the combination of acupuncture with education yielded the best results for smoking cessation.

Auricular acupuncture helps support young people in managing withdrawal symptoms that are often compounded by complex mental health issues and the challenges of residing in a custodial environment. Acupuncture is frequently provided to young people who are identified as being at risk of self-harm and/or suicide and that are being managed through the ACCT (Assessment, Care in Custody and Teamwork) process. In these instances the provision of auricular acupuncture forms part of the young person’s individual care map. The treatment provides them a quiet space for relaxation and an alternative method of coping which is very important in relation to reducing stress and anxiety.

An initial evaluation was undertaken at the request of the Keppel Unit Governor to examine the effectiveness of the auricular acupuncture programme on the Keppel Unit over a 7 month period 1st January and the 31st July 2013. This current report has built on the previous findings and looks specifically at the thirty seven self-completion evaluations by young people who finished a programme of auricular acupuncture between the 1st January 2013 and the 30th April 2014. Each six-week programme consisted of weekly sessions lasting up to forty-five minutes. It is prudent to note that within the 15 month period being examined there was one young person identified as requiring specialist clinical interventions with regards to withdrawing from a physically addictive substance (this does not include nicotine). Due to ethical issues that arise when working with young people and those with substance misuse problems Randomised Controlled Trials (RCT’s) were not conducted. Further more it would be unethical to withhold a treatment or provide a sham treatment for such a vulnerable group.

Methodology

A total of thirty seven young people were asked to complete evaluations to assess the effectiveness of auricular acupuncture, after completing a six-week programme (see appendix 1). The evaluations asked them to identify whether the following thirteen factors had improved, stayed the same or worsened since having the treatment: physical pain, depression, anxiety, cravings for drugs, cravings for alcohol, anger, energy, relationships, confidence, sleep, concentration, appetite and self esteem. Young people were asked to leave blank or write N/A next to those factors that were not applicable to them i.e. those that had not been an issue prior to the treatment or formed part of the referral, as the evaluation was specifically looking for changes in existing factors. They were also asked to rate the overall effectiveness of the treatment out of ten. In addition to the evaluations a random sample of four young people were also asked to describe their experience of the treatment, providing qualitative data to supplement the quantitative data generated by the questionnaires.

Results

The following charts depict how the young people rate the impact that the treatment has had on a number of physical and emotional factors. The graph for each factor identifies the percentage of young people that reported an improvement, a worsening, no change or that the factor was not an issue prior to the treatment. This format has been used to enable comparisons with the previous study.

Further analysis then focuses on the subset of young people that reported that the factor was an issue prior to the treatment (removing those who reported that the factor was not an issue i.e. N/A) and examines whether the factor improved, stayed the same or worsened.

Chart 1 – Physical pain

The data shows that 11% of the young people reported that physical pain had improved since the treatment and 11% reported that it had stayed the same. The majority, 78% identified that physical pain was not something that had been an issue prior to the treatment.

For those young people who indentified that physical pain had been an issue prior to the treatment 50% reported that it had improved and 50% reported there had been no change.In accordance with the referral criteria acupuncture can be used to support young people going through detoxification, which may include experiencing uncomfortable and painful physical withdrawal symptoms.

Chart 2 – Depression

The Shen Men point is attributed to relieving the symptoms and feelings of depression. The data identifies that over half, 54% reported that depression had improved with the treatment, 16% reported it had remained the same and 30% reported that depression had not been an issue prior to the treatment.

For those that had identified depression as an issue prior to the treatment 77% reported that it had improved and 23% reported that it had remained the same. Feelings of depression and low mood can be linked to the absence of substances.

Chart 3 – Anxiety

The Sympathetic point is attributed to relieving anxiety, worry and nervousness. 70% reported that anxiety had improved following the treatment, 14% reported that it had stayed the same and 16% reported that it was not an issue prior to the treatment.

For those that identified anxiety as an issue prior to the treatment 84% reported that it had improved and 16% reported it had remained the same. Anxiety management is often cited on auricular acupuncture referrals, particularly given that it manifests as a withdrawal symptom for most legal and illegal substances to varying degrees.

Chart 4 – Cravings for drugs

Over half 54% reported that cravings for drugs had improved and 11% reported they had stayed the same. 35% reported that cravings for drugs had not been an issue prior to the treatment.

For those that identified cravings as an issue prior to the treatment 83% reported that they had improved and 17% reported that they had remained the same.

It should be noted that this includes nicotine as well as illicit drugs and Novel Psychoactive Substances (NPS).

Chart 5 – Cravings for Alcohol

The data shows that 32% reported that cravings had improved and 14% reported they remained the same. A further 54% reported that cravings for alcohol were not an issue prior to the treatment.

For those that reported cravings for alcohol was an issue prior to the treatment 71 % reported an improvement and 29% reported they remained the same.
This is consistent in the continuing trend of reducing numbers of dependent drinkers that are entering the juvenile custodial estate.

Chart 6 – Anger

The Liver point in the 5-point auricular acupuncture treatment is attributed to reducing feelings of anger and frustration. The data identifies that 62% reported that it had improved, 24% reported that anger had remained the same and 14% reported that anger had not been an issue prior to the treatment.

For those that identified anger as an issue prior to the treatment 72% reported it had improvement and 28% reported that it had remained the same.

Chart 7 – Energy

The data shows that 44% reported that their energy levels improved, 35% reported they remained the same and 16% reported that energy levels had not an issue prior to treatment. This is only one of two factors which young people reported a worsening effect following the programme, 5% reported that energy levels had worsened since having the acupuncture.

For those that identified energy as an issue prior to the treatment 52% reported and improvement, 42% reported they were the same and 7% a worsening.

Chart 8 – Relationships

The data shows that just under half 46% reported an improvement in relationships with others, 35% reported they stayed the same and 19% reported that relationship problems were not an issue prior to the treatment.

The data shows that just under half 46% reported an improvement in relationships with others, 35% reported they stayed the same and 19% reported that relationship problems were not an issue prior to the treatment.

Those that identified relationships as an issue prior to the treatment 57% reported they had improved following the treatment and 43% reported no change.

This improvement has implications on the working relationships that young people have with staff and other young people on the unit as well as with family and friends.

Chart 9 – Confidence

The data shows that 32% reported that confidence had improved, 60 % reported it remained the same and only 8% reported that confidence was not an issue prior to the treatment.

For those that reported that confidence was an issue prior to the treatment 35% reported an improvement and 65% reported that it remained the same.

Chart 10 – Sleep

The vast majority, 65% reported that their sleep improved, 30% reported that it stayed the same and a small minority reported it had worsened 5%.

Chart 11 – Concentration

65% reported their concentration had improved, 30% reported that it remained the same and 5% reported it had not been an issue prior to the treatment.

For those that identified that concentration was an issue prior to the treatment 69% reported an improvement and 31% reported no change.

Chart 12 – Appetite

Just under a third, 32% reported their appetite improved, 49% reported it remained the same and 19% reported that it had not been an issue prior to the treatment.

For those that identified that appetite was an issue prior to custody 40% reported an improvement and 60% reported that it had remained the same.

Chart 13 – Self esteem

35% reported that their self esteem improved, 54% reported it remained the same and 11% reported that it had not been an issue prior to custody.

For those that identified self-esteem as an issue prior to the treatment 39% reported an improvement and 60% reported that it remained the same.

Summary Table

Factor Improvement
1 Anxiety 84%
2 Cravings for drugs 83%
3 Depression 77%
4 Anger 72%
5 Cravings for alcohol 71%
6 Concentration 69%
7 Sleep 65%
8 Relationships 57%
9 Energy 52%
10 Pain 50%
11 Appetite 40%
12 Self esteem 40%
13 Confidence 35%

The summary table highlights the percentage of young people that reported an improvement of a factor that had been an issue prior to the treatment. The percentages are weighted in the right direction with ten out of the 13 factors reflecting an improvement of 50% and over.

Overall score

Four respondents did not provide a rating and therefore were not included when calculating the mean average. The mean average of how effective young people rated the treatment in terms of meeting their needs was 8 out of 10.

Young Peoples Comments About The Treatment

In addition to the statistical data a random sample of the young people provided quotes about their experiences of the treatment:

“I felt really chilled and was thinking of lots’ of good memories and after I felt a bit high”.

“It was a really relaxing experience. Before I had it done I was a bit stressed and nervy but it took the edge off. Top marks, ten out of ten”.

“It’s good yes go and try it”.

“It’s really good thanks to Deividas and Dawn”.

“It was all good”.

Discussion

The young people referred to the Keppel Unit have complex needs that encompass factors already examined in this report: physical pain, depression, anxiety, cravings for drugs, cravings for alcohol, anger, energy, relationships, confidence, sleep, concentration, appetite and self-esteem. These factors are addressed through coordinated interventions and through specialist safeguarding procedures and processes such as the Assessment Care in Custody Teamwork (ACCT). The benefits of acupuncture are often drawn upon and added to the ACCT care plan. This research demonstrates that a six-week programme of auricular acupuncture contributes to a positive outcome for young people as improvement in all factors were recorded. It should be noted that some factors such as anxiety are more prevalent on acupuncture referrals and that none of the referrals over the 15 month period included addressing physical pain or suppressed appetite.

The findings focus on the improvements of factors that had been an issue prior to the treatment as this provides substantial evidence in relation to the benefits of the treatment rather than the validity of the evaluation forms used. The significant findings were that over half of the participants reported an improvement in ten of the thirteen factors following the treatment, a resounding 84% reported an improvement in anxiety, 83% reported an improvement in craving for drugs and 77% reported an improvement in depression. The summary table can be divided into subsections. The first 5 factors all demonstrate an improvement of over 70% and are arguably the factors that have the largest impact on behaviour management within the Prison.

It is well documented that problems with anxiety often have a negative impact on physical health, mental health, wellbeing and behaviour. Improvements in these factors have a positive affect on the young people’s ability to engage effectively in constructive activities and improve general functioning and wellbeing. It is therefore argued that participating in auricular acupuncture should be considered a healthy behaviour. In the community young people often mask and manage their anxiety through drug use and other maladaptive coping strategies, acupuncture teaches them an alternative method.

In recent years there has been an increase in the number of young people entering custody presenting with complex dual- diagnosis issues. Cannabis and Novel Psychoactive Substances (NPS) have given rise to more mental health problems such as anxiety and psychosis. Many young people experience feelings of anxiety as a result of being incarcerated which is compounded by withdrawal symptoms and cravings for drugs. This report highlights that the application of acupuncture in conjunction with specialist interventions from the Child and Adolescent Mental Health Service (CAMHS) and the Young People’s Substance Misuse Service (YPSMS) has been successful in relieving symptoms and treating these issues.

The benefits of the treatment have wider implications for the unit. 72% reported their anger had improved following the treatment. It could be argued that a reduction in anger could reduce the episodes of overt displays of anger and aggression that sometimes lead to violent behaviour towards others. Furthermore a reduction in anger, anxiety and depression could play a role in reducing incidents of self-harm. There is clearly an opportunity for further research to examine these suppositions in relation to the contribution that acupuncture makes to the Prison’s safeguarding and violence reduction strategies and the overall stability of the therapeutic environment.

In conclusion it is evident that auricular acupuncture is valued by the young people on the Keppel Unit and that it provides them a multitude of both physical and emotional benefits. Whilst the research is not subject to scientific rigour, the anecdotal evidence is overwhelming in support of the treatment. It allows the young people in custody the opportunity to experience different types of treatment rather than having a limited range of more prescriptive interventions. The role of acupuncture is far reaching and is used in detoxification care plans, Assessment Care in Custody Teamwork (ACCT) care plans and sentence plans and provides an additional source of support. All of these measures support and safeguard young people and contribute to the stability of the unit. As a result of these findings a number of recommendations have been made.

Recommendations

  • – The findings in this report highlight the benefits of the auricular acupuncture treatment when delivered as part of an integrated care plan and it is strongly recommended that the delivery of the well established auricular acupuncture programme on the unit should continue.
  • – The findings of this report should be submitted to the commissioners of the YPSMS and the new service providers.
  • – Annual findings should be submitted to NICE, Public Health England and NADA to further the evidence base for this treatment.
  • – The self evaluation questionnaire to be revised and focused on specific factors that make up the largest proportion of the referrals.
  • – Future research could encompass feedback from staff on the unit working with the young people that have completed the acupuncture programme.
  • – An annual evaluation of the programme should be completed. It is estimated that between 25 and 30 young people will complete a six- week programme of auricular acupuncture within a year.
  • – Further research can be commissioned to examine the wider implications of auricular acupuncture on the Keppel Unit. For example the reduction in incidents of violence or self-harm.

References

Bier, I., Wilson, J., Shakleton, M. (2002) ‘Auricular acupuncture, education, and smoking cessation: A randomized, sham-controlled trial’, American Journal of Public Health, vol 92 (10) 1642-1647

Chitsabesan, p., Kroll, L., Bailey. S., Kenning, C., Sneider, S., MacDonald, W. and Theodosiou, L. (2006) ‘ Mental health needs of young offenders in custody and in the community’, The British Journal of Psychiatry, vol 188 534-540

Etchelles, P. (2013) ‘Healthy behaviour and well-being’, The Psychologist, vol. 26 (10) 712

NICE (2008) ‘Opioid detoxification national clinical practice guideline number 52. National collaboration centre for mental health commissioned by the national institute for health and clinical excellence’, The British Psychological Society and The Royal College of Psychiatrists, London 1-271 http://www.nice.org.uk/nicemedia/live/11813/35999/35999.pdf (accessed 13 October 2013)

NICE (2011) ‘Alcohol use disorders: diagnosis, assessment and management of harmful drinking and alcohol dependence’, NICE Clinical guideline 115, Manchester 1-51 Available at http://www.nice.org.uk/nicemedia/live/13337/53191/53191.pdf (accessed 13 October)

Perkin, M., Pearcy, R. and Fraser, J. (1994) ‘A comparison of the attitudes shown by general practitioners, hospital doctors and medical students towards alternative medicine’ Journal of the Royal Society of Medicine, vol. 87 523

Wang,S., Zeev, N.K. (2001) ‘Auricular acupuncture: A potential treatment for anxiety’ The international Anesthesia research society vol 92 548-53 http://www.nadauk.com/ (accessed 13 October)

http://www.nadauk.com/node/9 (accessed 13 October)

Appendix 1

HM YOI Wetherby
Auricular Acupuncture
Evaluation Form

The conditions below are the most commonly reported states of mind and body that people seek to find relief from with electro stimulation therapy.

For each observation tick the box you feel most applies to you.

STATEMENT: Since starting Auricular Acupuncture treatments I have noticed the following:

kettle results template

On a scale of 1-10, how would you rate the benefits of this treatment (1 = don’t rate it at all – 10 = rate it extremely high

rate out of ten

Please feel free to make any further comments and thank you for your help in this evaluation.