Substance Use Disorder Treatment: Complementary Approaches

Introduction

Complementary and alternative medicine (CAM) practices can improve chances of recovery from substance use disorders (SUDs), especially when used in addition to traditional SUD treatments and mutual self-help groups. They are not meant to replace traditional (conventional) treatments, however. Traditional treatments are important for the development and maintenance of solid recovery, which often includes treating co-occurring physical or mental health conditions, improving relapse prevention, improving inter- and intra-personal interaction skills, and rebuilding the areas of one’s life that have been affected by substance use. Complementary practices provide additional tools that can enhance various aspects of the patient’s recovery; many patients find CAM practices a helpful and enjoyable part of their recovery.

CAM practices include a variety of practices or techniques administered or taught by a trained instructor.[1] Specific practices include acupuncture, massage therapy, deep breathing, meditation (mindfulness or transcendental), guided imagery, movement therapies (e.g., Feldenkrais method, Alexander technique, Pilates, Rolfing Structural Integration, Trager psychophysical integration), relaxation techniques, spinal manipulation, tai chi, qi gong, yoga, and hypnotherapy to name a few.[1] For more information, refer to “Introduction to Complementary Approaches.”

The complementary approaches listed below are sometimes classed as mind-body practices, but they may also be classed in other ways (e.g., yoga is sometimes classed as a movement-based therapy, and energy medicine approaches are sometimes placed in a category of their own. Be that as it may, many of these practices have been linked to improvements in general physical and mental health and well-being, the ability to better cope with daily challenges and stressors, and the enhancement of the healing process in SUDs. They can be effective methods for improving self-care, which is vital to SUD recovery.

Research on Complementary Approaches for SUDs

Overall, evidence on the efficacy of CAM mind-body practices as adjunct therapies for SUDs is promising but limited, calling for further research in this area. CAM practices are generally considered safe if practiced appropriately and administered by trained providers or instructors adhering to the proper safety practices. Although conclusive evidence for a given CAM practice may not exist, if the patient is interested and motivated to pursue it, and the therapy appears safe, it may be beneficial to encourage such efforts, because some individuals may find these practices extremely helpful for their recovery. One can use the ECHO (Efficacy, Cost, Harm, and Opinions) tool as a guide to choosing therapies. For more information, refer to “Deciding if an Approach Is Worth Using: The E.C.H.O. Mnemonic.”

Mindfulness meditation

Mindfulness meditation is a popular mind-body practice that helps train the mind in nonjudgmental attention to present moment experiences (“mindful awareness”). This involves bringing nonjudgmental attention to one’s thoughts, emotions, and sensations occurring in the present moment, and letting them be as they are, by simply observing as they come and go, with acceptance. In recent years, mindfulness-based interventions have become the most commonly evaluated and applied meditation interventions in clinical and non-clinical settings, with research evidence supporting their efficacy for many mental health and physical conditions.[2] Mindfulness meditation is one mind-body practice that is of particular relevance to SUD recovery, as it has shown benefits for depression, anxiety, pain, and stress coping, and possible benefits for PTSD,[3,4] all common problems among Veterans and documented relapse risk factors in SUDs. Mindfulness meditation practice can benefit the “whole person,” and shows some promise for SUDs,[3,5,6] including smoking cessation.[7]

There is growing research evidence supporting the use of mindfulness-based approaches as an adjunct therapy for SUDs; however, conclusive data are still lacking.[3,5,6] While some studies suggested reduced substance use (variety of drugs, alcohol, nicotine) and craving after mindfulness training, others did not appreciate benefits or showed inconsistent results, especially when compared to a control condition.[2,3,5,6] It is unclear, though, which persons with SUDs might benefit most from mindfulness training.

Mindfulness-based relapse prevention (MBRP) is an intervention developed specifically for patients with SUDs.[8] This program integrates mindfulness meditation with cognitive therapy relapse prevention skills, and is intended for and best suits patients who have completed initial treatment for SUDs (inpatient or outpatient), are motivated to maintain recovery goals, and are open to making lifestyle changes to support their recovery.[8] The MBRP course typically consists of 8 weekly sessions, delivered in a group format by trained meditation instructors, with each session including practice, discussion, topic-specific exercises, and home practice. Clinicians interested in facilitating an MBRP should receive MBRP facilitator training; it should be emphasized that facilitators’ personal meditation practice is the foundation for teaching patients meditation-based practices.[8] Cultivating skills in mindful, nonreactive awareness of relapse triggers (thoughts, feelings, sensations, environmental factors) and other experiences as they are occurring is a key part of self-management in recovery. Mindfulness meditation can additionally support healing of body and mind, and the pursuit of personal growth goals, and it can exert positive effects on quality of life and general health.

For more information, refer to the “Mindful Awareness” and related tools.

Transcendental meditation

Transcendental meditation (TM) refers to a mantra form of meditation. It involves repeating in one’s mind a short phrase (“mantra”) for a given length of time. A mantra is typically assigned to a practitioner by the certified TM teacher. Evidence on the efficacy of TM in SUDs is less extensive and more inconsistent than for mindfulness meditation.[9] Potential benefits of TM may include decreased drug, alcohol, and tobacco use.[10]

In general, caution should be taken with any type of meditation practice (e.g., mindfulness meditation, transcendental meditation) in patients with underlying substantial mental health issues; these patients are recommended to consult with their mental health provider before beginning a meditation program.[11]

Yoga

There are many different styles of yoga (e.g., Hatha, Vinyasa, Ashtanga); some are gentler, such as Hatha yoga, and some are more physically challenging, such as Ashtanga yoga. Yoga involves engaging in various movements, stretches, and postures, typically to the rhythm of the breath. It is important for the clinician to discuss the risks and benefits of yoga with patients, as some poses may need to be avoided in patients with certain health conditions.[11] Yoga can be helpful for relieving inner and outer tension and increasing a sense of well-being and connection with oneself. Therefore, through reducing stress and tension, known relapse risk factors, yoga can enhance recovery. Preliminary research suggests that yoga may be a beneficial adjunctive treatment for SUDs,[12] including smoking cessation;[7] however, more research is needed.[11] For additional information, refer to “Yoga: Looking Beyond “The Mat.”

Acupuncture

Acupuncture is a procedure involving stimulation of targeted points on the body using thin, solid, metal needles that are manipulated by hand or using electrical stimulation.[13]Acupuncture should be performed by an experienced practitioner using sterile needles.[13] Some patients enjoy using acupuncture as a self-care practice. It is important to discuss the potential risks of acupuncture with patients with certain medical conditions or who use medications that increase the risk of bleeding.[11,13] Limited research on acupuncture has produced mixed results, providing only minimal evidence for potential benefits as an adjunctive treatment for SUDs.[14-17] For more information, refer to “Acupuncture and Traditional Chinese Medicine .”

Massage

Massage can be helpful for relaxation, rejuvenation, and alleviation of muscle tension and many people enjoy massage as a part of self-care. Preliminary evidence has shown its potential benefit for alleviating symptoms of alcohol withdrawal[18] and reducing anxiety in alcohol, cocaine, and opiate withdrawal.[19] Refer to “Massage Therapy.”

Energy therapies

Energy therapies use energy fields including the unconventional use of electromagnetic fields (e.g., transcranial magnetic stimulation, TMS) or biofield manipulations (e.g., qi gong, Reiki, therapeutic touch). Very limited support exists for these practices as therapies for SUDs. TMS is a noninvasive intervention where a clinician stimulates certain parts of a patient’s brain using a machine emitting electromagnetic field. One preliminary study showed the potential of TMS for reducing alcohol craving in alcohol-dependent adults.[20] For general information on these approaches, refer to “Energy Medicine.”

Qi gong

Qi gong is a technique that combines mental focus, deep breathing, and gentle physical movements;[21] preliminary evidence shows potential benefits of qi gong in reducing withdrawal symptoms, craving, and anxiety in SUDs,[22] but more research is needed.

Biofeedback

Biofeedback therapy is a process that involves training patients to regulate bodily functions consciously (e.g., breathing, heart rate, blood pressure) to improve overall health.[23]Biofeedback is used for reducing stress, headaches, and pain and for reconditioning injured muscles and controlling asthma attacks.[23] There is very little research of the effects of biofeedback in SUDs. Preliminary evidence has suggested possible benefits of electroencephalogram (EEG) biofeedback for reducing craving, depression, and anxiety symptoms in inpatients with polysubstance abuse.[24]

Hypnotherapy

Hypnotherapy is a possible tool that may help manage one’s internal landscape and response to triggers. Clinical hypnosis is guided by a licensed, trained clinician and is used for treating a psychological or physical problem. The patient is guided into an altered state of awareness, perception, or consciousness where suggestions are then made by the clinician, or communication is had between patient and clinician, to help guide the patient toward the problem they are trying to resolve.[25] One preliminary study of Veterans with drug and alcohol use disorders and co-occurring mental health disorders suggested positive effects of hypnosis on abstinence, self-esteem, anger, and impulsivity.[26] However, evidence is inconclusive for the use of hypnotherapy in SUDs.[11] It is recommended to use hypnotherapy cautiously in patients with psychosis/schizophrenia, bipolar disorder, multiple personality disorder, dissociative disorders, and seizure disorders.[11]

Guided imagery/visualization

Guided imagery or visualization is the practice of using one’s imagination to facilitate a relaxed state. Many individuals find this practice enjoyable. Research is scant on guided imagery as an adjunctive therapy for SUDs. However, preliminary evidence indicates it may be helpful as an adjunct treatment for long-term smoking cessation.[11]

Music therapy

Music therapy is provided by a properly credentialed professional and involves the use of music-based interventions (e.g., creating, singing, moving to, and/or listening to music) to help accomplish individual goals that are tailored to the patient’s individual needs and preferences.[27] Many people find music therapy relaxing and enjoyable; however, due to limited research evidence, there is no consensus regarding the efficacy of music therapy as an adjunctive treatment for SUDs.[28]

For more information on mind-body therapies, such as hypnotherapy, biofeedback, and guided imagery, refer to “Power of the Mind” and related tools. Resource Boxes 1-4 below feature additional information on various complementary/mind-body approaches for substance use disorders.

Resource Box 1. Complementary Approaches for Substance Use Disorders: Descriptions, Session Formats, and Links


Acupuncture

Stimulation of targeted points on the body using thin, solid metal needles that are manipulated by hand or using electrical stimulation [13]

  • Individual format
  • National Center for Complementary and Alternative Medicine—Acupuncture

Biofeedback

Teaches conscious regulation of bodily functions (e.g., breathing, heart rate, blood pressure) to improve overall health[23]

  • Individual format
  • National Center for Complementary and Alternative Medicine—Biofeedback Information (general information):

Hypnotherapy

Hypnosis under the care of a trained clinician, used to help guide the mind in a way to facilitate changes that brings one toward their desired goals

Massage

Manipulation of muscle and tissue to enhance function of those areas and promote relaxation and well-being[23]

Mindfulness-based cognitive therapy (MBCT)

Teaches mindfulness-based skills to assist with depression, anxiety, and other mental health disorders/conditions

Mindfulness-based relapse prevention (MBRP)

Teaches mindfulness-based relapse prevention skills for SUDs

Mindfulness-based stress reduction (MBSR)

Teaches mindfulness-based skills for general health and well-being

Music therapy

Uses music-based interventions to help accomplish individual goals (e.g., creating, singing, moving to, and/or listening to music), and are tailored to the patient’s individual needs and preferences

Qi gong

Combines specific movements or postures, coordinated breathing, and mental focus

Relaxation technique: Deep breathing

Breathing in and out slowly and deeply through the nose, usually to a count of 10 for each in-breath and out-breath[23]

Relaxation technique: Guided imagery

Using the imagination to facilitate a relaxed state

Transcendental meditation

Recitation of a mantra that is assigned by a certified TM teacher

Transcranial magnetic stimulation (TMS)

A noninvasive intervention where a clinician stimulates certain parts of the brain using a machine emitting electromagnetic fields

  • Individual format
  • Inquire about local resources

Yoga (e.g., Hatha, Vinyasa, Ashtanga)

Engaging in various movements and postures to the rhythm of the breath—Hatha yoga is the most gentle

  • Group or Individual format
  • National Center for Complementary and Alternative Medicine—Yoga for Health

Resource Box 2. Mindfulness-Based Relapse Prevention: SOBER Brief Meditation


SOBER Brief Meditation

This meditation is especially helpful when having thoughts or urges to use a substance, or when feeling a need to automatically react to a particular situation. This meditation helps to create a pause in your experience to allow you to reground and make a choice about how to respond, instead of automatically reacting to an internal experience or external situation.

Stop: right here and right now; this pause can allow you to step out of autopilot (instead of automatically reacting to an urge, or distressing situation)

Observe: what is happening right now, in this moment—what’s going on in your mind and body; bring gentle awareness to your thoughts, sensations, and emotions

Breathe: bring your attention to the sensations of each breath

Expand: expand your awareness to include a sense of the body and mind as a whole

Respond: now, try to make a mindful choice what to do next (if anything)

Adapted from Mindfulness-Based Relapse Prevention[6]

Resource Box 3. Mind-Body Tools: Introductory Basic Mindfulness Meditation Practice for Relapse Prevention


Basic Mindfulness Meditation

Find a chair and settle into a comfortable sitting position…. Allow your eyes to close (or keep them gently open with your gaze tilted slightly toward the floor). Allow yourself to have a relaxed posture, with your back straight, your head resting gently on top, and with the bottoms of both feet planted on the floor…. Your posture should be relaxed and dignified, not stiff…. Sitting this way helps the breath flow easily.

Now, bring your awareness to any sensations of touch or pressure in the body, where it makes contact with the floor or chair…. Notice the sensations of the bottoms of the feet making contact with the floor…. Bring awareness to the point of contact between your legs and the chair…. Take a moment to notice the sensation of touch or pressure in various parts of the body….

Now bring your awareness to the breath as it moves in…and out of your body…. It may be helpful to place your hand on your lower belly and become aware of the sensations of the breath there…. Just noticing each…in-breath…and…out-breath….

Notice the sensations of the abdominal wall as it rises with each in-breath, and gently falls with each out-breath…. There is no need to control your breathing in any way—simply let the breath breathe itself….

When you notice that your mind has wandered away from the focus on the breath to thoughts, planning, daydreams, drifting along, this is perfectly OK—it’s simply what minds do. It is not a mistake. Simply let go of these thoughts and gently congratulate yourself—you have become aware of your experience again—now bring your awareness back to the breath….

Each time you notice that your mind has wandered, gently bring your awareness back to the breath, using your breath as an anchor to connect with the present moment, the here and now….

And now, take a few more seconds, noticing each in-breath and out-breath… and when you are ready, open your eyes.

Adapted from Mindfulness-Based Relapse Prevention for the Treatment of Alcohol Dependence: Eight-Week Course Research Manual[29]

Resource Box 4. Mind-Body Tools for Substance Use Disorders: Visualization/Guided Imagery Example


Visualization/Guided Imagery Example

Visualization or guided imagery involves using your imagination to facilitate a relaxed state.

Start by closing your eyes. Allow yourself to get into a comfortable position…Begin with a few slow deep breaths, letting your body relax. Let the chair fully support your body as you continue to breathe and relax…. Imagine yourself slowly walking down a path—it can be any path you wish. It’s a beautiful day, and you feel relaxed and happy…. You can feel the warmth and energy of the sun on your skin…. Soon you come to a gate. You know this gate leads to a special place where you feel welcome, safe, and comfortable. Push the gate open and allow yourself to enter the garden. Your garden is filled with your favorite things. Notice the details of your surroundings in your garden—the sights, the sounds, the smells. Notice the variety of things in your garden…. Everything peacefully co-exists here…. Begin to explore this place with your sense of touch. Perhaps some things are soft and warm and others smooth and cool…. Notice what the air feels like…. Now become aware of the sounds that exist in your garden…. Perhaps your garden is quiet…perhaps there are a variety of sounds. Some of the sounds may be soft; others louder…. Become aware of the different smells in your garden…. Perhaps noticing different fragrances that are soothing…. Take your time in your garden, using it in whatever way you wish…. Spend the time that is necessary for you to rejuvenate and to care for yourself….

When you are ready to leave, slowly walk back toward the garden gate…. You have enjoyed your visit and feel relaxed and content…. This good feeling will remain with you throughout the day…. Push the gate open and return to the path that led you to the garden, remembering that you can use your imagination to return to your garden at any time you wish…. When you are ready, stretch gently and open your eyes.

Adapted from “The Private Garden” from the Department of Veterans Affairs[30]

Author(s)

“Substance Use Disorder Treatment—Mind-Body Practices and Other Complementary Approaches” was written by Aleksandra Zgierska, MD, PhD and Cindy A. Burzinski, MS, LPCT, SACIT (2014).

References

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