Integrative management of Integrative management of alcohol and substance abusealcohol and substance abuse

Presented to:Presented to:Integrative Mental Health of OregonIntegrative Mental Health of Oregon

20 February, 200920 February, 2009

James Lake MDJames Lake MDwww.IntegrativeMentalHealth.net

Clin. Asst. Professor, Stanford Clin. Asst. Professor, Stanford PsychiatryPsychiatry

Unmet needsUnmet needs

• Annual costs associated with alcohol and Annual costs associated with alcohol and drug abuse in U.S. estimated at $246 billiondrug abuse in U.S. estimated at $246 billion

• High cost of alcohol and drug abuse High cost of alcohol and drug abuse reflects a crisis of epidemic proportions reflects a crisis of epidemic proportions that has not been adequately that has not been adequately addressed by available conventional addressed by available conventional treatments including mainstream treatments including mainstream pharmacological treatments, pharmacological treatments, psychotherapy and social programs.psychotherapy and social programs.

Conventional therapies only Conventional therapies only moderatelymoderately effective effective

• Controlled trials and patient surveys Controlled trials and patient surveys confirm that many conventional confirm that many conventional pharmacological and psychosocial Rx pharmacological and psychosocial Rx of alcohol and drug abuse or of alcohol and drug abuse or dependence are dependence are only moderately only moderately effective effective in terms of discontinuation in terms of discontinuation rates and long-term abstinence rates and long-term abstinence (Carroll, 1996; McLellan, Metzger, (Carroll, 1996; McLellan, Metzger, Alterman, Cornish, & Urschel, 1992; Alterman, Cornish, & Urschel, 1992; Emrick, 1987).Emrick, 1987).

Integrative Management Integrative Management begins with history and begins with history and

assessmentassessment• History: sx severity, course, co-morbid psychiatric History: sx severity, course, co-morbid psychiatric

and medical problems, previous conventional and and medical problems, previous conventional and CAM Rx.CAM Rx.

• Assessment: interview, labs if indicated, identify Assessment: interview, labs if indicated, identify cultural, social, psychological, biological factors cultural, social, psychological, biological factors contributing to substance abusecontributing to substance abuse

• Treatment planning: consider patient preferences, Treatment planning: consider patient preferences, resources, financial constraints, what has worked resources, financial constraints, what has worked before before

• An optimum integrative plan includes established An optimum integrative plan includes established safe conventional pharmacological/psychosocial Rx safe conventional pharmacological/psychosocial Rx and the non-conventional Rx that are safe in and the non-conventional Rx that are safe in combination with conventional therapies acceptable combination with conventional therapies acceptable to the patient, locally available and affordable.to the patient, locally available and affordable.

Non-pharmacological Non-pharmacological therapiestherapies• Part I: Part I: directdirect biological effects biological effects

– dietary modifications (alcohol abuse)dietary modifications (alcohol abuse)– vitamins and minerals (alcohol abuse)vitamins and minerals (alcohol abuse)– amino acidsamino acids– medicinal herbsmedicinal herbs

• Part II: Part II: indirect indirect biological effectsbiological effects – exercise exercise – mindfulness training mindfulness training – cranio-electrotherapy stimulation, cranio-electrotherapy stimulation, – virtual reality graded exposure therapy virtual reality graded exposure therapy – light exposure therapy light exposure therapy – acupunctureacupuncture– qigong qigong

Complementary vs integrative Complementary vs integrative managementmanagement

• Most non-conventional approaches can be Most non-conventional approaches can be used alone or together with established used alone or together with established pharmacological or psychosocial Rxpharmacological or psychosocial Rx

• Studies on comparative efficacy of Studies on comparative efficacy of integrative vs stand-alone CAM or integrative vs stand-alone CAM or conventional modalities have not been doneconventional modalities have not been done

• Critical role of patient motivation, Critical role of patient motivation, autonomy and supportive environment autonomy and supportive environment (12-step group) for success of any (12-step group) for success of any treatment programtreatment program

Dietary modificationDietary modification

• Malnourishment caused by malabsorption of Malnourishment caused by malabsorption of essential nutrients through the mucosa of essential nutrients through the mucosa of the stomach and small intestines, resulting the stomach and small intestines, resulting in reduced serum levels of thiamine, folate, in reduced serum levels of thiamine, folate, vitamin B6 (Gloria et al 1997) vitamin B6 (Gloria et al 1997)

• Hypoglycemia results from toxic effects of Hypoglycemia results from toxic effects of alcohol on the liver and can manifest as alcohol on the liver and can manifest as confusion, anxiety, and impaired cognitive confusion, anxiety, and impaired cognitive functioning. functioning.

Dietary modificationDietary modification

• Rational approaches to malnourishment Rational approaches to malnourishment in chronic alcoholics include avoidance in chronic alcoholics include avoidance of refined carbohydrates, and increased of refined carbohydrates, and increased consumption of complex carbohydrates consumption of complex carbohydrates and protein. and protein.

• Improved general nutrition correlates Improved general nutrition correlates with higher abstinence rates (Guenther, with higher abstinence rates (Guenther, 1983; Lieber 1991)1983; Lieber 1991)..

Vitamins and minerals Vitamins and minerals (alcohol abuse)(alcohol abuse)• Low serum thiamine levels possibly correlated to Low serum thiamine levels possibly correlated to

increased alcohol craving (Zimatkin & Zimatkina, increased alcohol craving (Zimatkin & Zimatkina, 1996) 1996)

• Niacin (nicotinamide (1.25 g) taken with a meal Niacin (nicotinamide (1.25 g) taken with a meal before drinking may protect the liver against before drinking may protect the liver against acute toxic effects of alcohol (Volpi et al., 1997) acute toxic effects of alcohol (Volpi et al., 1997)

• When a patient is unable to stop drinking, taking When a patient is unable to stop drinking, taking antioxidant vitamins close to the time of alcohol antioxidant vitamins close to the time of alcohol consumption consumption may reduce or preventmay reduce or prevent hangover hangover symptoms by neutralizing metabolites of alcohol symptoms by neutralizing metabolites of alcohol that cause oxidative damage to the brain (Altura that cause oxidative damage to the brain (Altura & Altura, 1999; Marotta et al., 2001) & Altura, 1999; Marotta et al., 2001)

Vitamins and minerals Vitamins and minerals (alcohol abuse)(alcohol abuse)

• Taking vitamin C (2 g) 1 hour before Taking vitamin C (2 g) 1 hour before alcohol consumption increases the rate at alcohol consumption increases the rate at which alcohol is cleared from the blood, which alcohol is cleared from the blood, possibly reducing acute toxic effects on possibly reducing acute toxic effects on the liver (Chen, Boyce, & Hsu, 1990)the liver (Chen, Boyce, & Hsu, 1990)

• Deficiencies in zinc, copper, manganese, Deficiencies in zinc, copper, manganese, and iron are common in alcoholics and and iron are common in alcoholics and worsen with continued heavy drinking.worsen with continued heavy drinking.

Vitamins and minerals Vitamins and minerals (alcohol abuse)(alcohol abuse)• Magnesium supplementation at 500 to 1500 Magnesium supplementation at 500 to 1500

mg/day may improve neuropsychological deficits mg/day may improve neuropsychological deficits associated with chronic alcohol abuse by associated with chronic alcohol abuse by improving cerebral blood flow, which is often improving cerebral blood flow, which is often diminished in alcoholics (Thomson, Pratt, diminished in alcoholics (Thomson, Pratt, Jeyasingham, & Shaw, 1988) Jeyasingham, & Shaw, 1988)

• Probable benefits and no contra-indicationsProbable benefits and no contra-indications to dietary modifications or supplementation with to dietary modifications or supplementation with the vitamins and minerals when taking the vitamins and minerals when taking conventional drug therapies for the management conventional drug therapies for the management of relapse prevention, craving or withdrawal. of relapse prevention, craving or withdrawal.

Vitamins and minerals Vitamins and minerals (alcohol abuse)(alcohol abuse)

• All individuals who struggle with alcohol or All individuals who struggle with alcohol or drug abuse, or who are in recovery following drug abuse, or who are in recovery following chronic abuse, should be strongly chronic abuse, should be strongly encouraged to optimize their nutritional encouraged to optimize their nutritional status by status by changing eating habits and changing eating habits and taking appropriate supplements to taking appropriate supplements to compensate for a probable alcohol-compensate for a probable alcohol-related malabsorption syndrome, to related malabsorption syndrome, to mitigate the toxic effects of abuse on mitigate the toxic effects of abuse on the body and brain, and to reduce the body and brain, and to reduce craving and the severity of withdrawal.craving and the severity of withdrawal.

Amino acids: general Amino acids: general (alcohol abuse)(alcohol abuse)

• Malnutrition and malabsorption in Malnutrition and malabsorption in chronic alcoholics often lead to chronic alcoholics often lead to deficiencies in important amino acids deficiencies in important amino acids including taurine, SAMe, tyrosine, L-including taurine, SAMe, tyrosine, L-tryptophan, and acetyl-L-carnitine. tryptophan, and acetyl-L-carnitine.

• Supplementation with amino acids helps Supplementation with amino acids helps to lessen the severity of withdrawal to lessen the severity of withdrawal symptoms, protect the liver, and restore symptoms, protect the liver, and restore normal brain function in chronic normal brain function in chronic alcoholics.alcoholics.

Amino acids: taurine Amino acids: taurine (alcohol abuse)(alcohol abuse)• Taurine supplementation Taurine supplementation maymay lower the serum lower the serum

level of acetaldehyde, a toxic metabolite of level of acetaldehyde, a toxic metabolite of alcohol that can interfere with normal mental alcohol that can interfere with normal mental functioning (Watanabe, Hobara, & Nagashima, functioning (Watanabe, Hobara, & Nagashima, 1985) 1985)

• Small controlled trial, 60 patients hospitalized for Small controlled trial, 60 patients hospitalized for acute alcohol withdrawal were randomized to acute alcohol withdrawal were randomized to taurine (1 g 3 TID) versus placebo. Significantly taurine (1 g 3 TID) versus placebo. Significantly fewer severe withdrawal symptoms, including fewer severe withdrawal symptoms, including delirium and hallucinations, were observed in the delirium and hallucinations, were observed in the taurine group (Ikeda, 1977). taurine group (Ikeda, 1977). Needs replicationNeeds replication

Amino acids: SAMeAmino acids: SAMe(alcohol abuse)(alcohol abuse)• SS-adenosylmethionine normally present in -adenosylmethionine normally present in

the liver is depleted by chronic alcohol the liver is depleted by chronic alcohol abuse. abuse.

• Chronic alcoholics who take SAMe at doses Chronic alcoholics who take SAMe at doses of 400 to 800 mg/day of 400 to 800 mg/day maymay have less severe have less severe liver damage (Lieber, 1997, 2000a,b). liver damage (Lieber, 1997, 2000a,b).

• SAMe is a logical choice when treating SAMe is a logical choice when treating depressed patients who abuse alcoholdepressed patients who abuse alcohol (Agricola, Dalla Verde, & Urani, 1994). (Agricola, Dalla Verde, & Urani, 1994).

• SAMe supplementation SAMe supplementation maymay reduce alcohol reduce alcohol intake (Cibin et al., 1988). intake (Cibin et al., 1988).

Amino acids: L-tryptophanAmino acids: L-tryptophan

• Low serum levels of l-tryptophan are correlated Low serum levels of l-tryptophan are correlated with low serotonin in a subset of alcoholics who with low serotonin in a subset of alcoholics who are at increased risk of developing early-onset are at increased risk of developing early-onset alcoholism associated with antisocial behavior alcoholism associated with antisocial behavior suggesting that suggesting that long-term supplementation long-term supplementation with L-tryptophan (or 5-HTP) may be a with L-tryptophan (or 5-HTP) may be a useful preventive intervention in this high-useful preventive intervention in this high-risk populationrisk population (Virkkunen & Linnoila, 1993) (Virkkunen & Linnoila, 1993)

• Taking l-tryptophan before drinking may reduce Taking l-tryptophan before drinking may reduce the severity of cognitive impairment associated the severity of cognitive impairment associated with alcohol use (Westrick, Shapiro, Nathan, & with alcohol use (Westrick, Shapiro, Nathan, & Brick, 1988) Brick, 1988)

Amino acids: ALC and Amino acids: ALC and tyrosinetyrosine• Abstinent alcoholics treated with Abstinent alcoholics treated with

acetyl-l-carnitine at doses of 2 g/day acetyl-l-carnitine at doses of 2 g/day for 3 months performed better on for 3 months performed better on tests of memory, reasoning, and tests of memory, reasoning, and language compared with a matched language compared with a matched control group (Tempesta et al., 1990) control group (Tempesta et al., 1990)

• Tyrosine may be a useful adjunctive Tyrosine may be a useful adjunctive treatment in cocaine abuse (Tutton & treatment in cocaine abuse (Tutton & Crayton, 1993)Crayton, 1993)

Amino acids—Amino acids—safetysafety

• Few safety problems when typically recommended Few safety problems when typically recommended doses of quality brand amino acid supplements are doses of quality brand amino acid supplements are combined with conventional psychiatric combined with conventional psychiatric medications (Berlanga, Ortega-Soto, Ontiveros and medications (Berlanga, Ortega-Soto, Ontiveros and Senties 1992; Levitan, Shen, Jindal, Driver, Senties 1992; Levitan, Shen, Jindal, Driver, Kennedy and Shapiro 2000). Kennedy and Shapiro 2000).

• Rare cases of serotonin syndrome have been Rare cases of serotonin syndrome have been reported when L-tryptophan, 5-HTP or SAMe are reported when L-tryptophan, 5-HTP or SAMe are used concurrently with serotonergic drugs (Turner, used concurrently with serotonergic drugs (Turner, Loftis, Blackwell 2006; (Pancheri, P., Scapicchio, P., Loftis, Blackwell 2006; (Pancheri, P., Scapicchio, P., Chiaia, 2002). Chiaia, 2002).

• Safety concerns have not been reported when Safety concerns have not been reported when combining taurine or acetyl-L-carnitine with combining taurine or acetyl-L-carnitine with conventional psychiatric medications.conventional psychiatric medications.

Herbal treatments of alcohol Herbal treatments of alcohol abuse: Kudzu and abuse: Kudzu and MentatMentat• Kudzu (Kudzu (Radix puerariaeRadix puerariae)) has been used in has been used in

Chinese medicine as a treatment of alcohol Chinese medicine as a treatment of alcohol abuse and dependence for almost 2000 years. abuse and dependence for almost 2000 years.

• Reduced alcohol craving is related to high plant Reduced alcohol craving is related to high plant concentrations of two isoflavones: daidzein and concentrations of two isoflavones: daidzein and daidzindaidzin (Lukas S, Penetar D, Berko J et al, 2005). (Lukas S, Penetar D, Berko J et al, 2005).

• In a one-week placebo-controlled study 14 heavy In a one-week placebo-controlled study 14 heavy drinkers pre-treated with a Kudzu (1000mg TID) drinkers pre-treated with a Kudzu (1000mg TID) versus placebo drank significantly less but did versus placebo drank significantly less but did not report diminished alcohol craving not report diminished alcohol craving

• More studies are neededMore studies are needed to confirm the effect to confirm the effect of kudzu on reducing alcohol consumption in at of kudzu on reducing alcohol consumption in at risk populations.risk populations.

MentatMentat™ for relapse ™ for relapse preventionprevention

• Findings of a small open trial suggest Findings of a small open trial suggest that that MentatMentat, ™ a proprietary , ™ a proprietary Ayurvedic compound herbal formula, Ayurvedic compound herbal formula, maymay reduce the risk of relapse in reduce the risk of relapse in abstinent alcoholics (Trivedi 1999).abstinent alcoholics (Trivedi 1999).

• Needs replication with controlled Needs replication with controlled trialtrial

Ashwagandha and GinsengAshwagandha and Ginseng• Animal studies and human case reports suggest Animal studies and human case reports suggest

Ashwagandha (Ashwagandha (Withania somniferaWithania somnifera) lessens ) lessens severity of withdrawal from morphine (Ramarao severity of withdrawal from morphine (Ramarao et al, 1995; Kulkarni & Ninan, 1997). et al, 1995; Kulkarni & Ninan, 1997).

• Ashwagandha is sedating and caution should be Ashwagandha is sedating and caution should be exercised when combined with benzodiazepines exercised when combined with benzodiazepines or other sedative-hypnotics.or other sedative-hypnotics.

• Ginseng (Ginseng (Panax ginsengPanax ginseng) may reduce tolerance ) may reduce tolerance and dependence in chronic abuse of cocaine, and dependence in chronic abuse of cocaine, methamphetamine or morphine (Kim 1990; Kim methamphetamine or morphine (Kim 1990; Kim 1994; Huong 1996). 1994; Huong 1996).

Peruvian herb for narcotic Peruvian herb for narcotic withdrawalwithdrawal

• Early findingsEarly findings suggest that suggest that glycosides derived from glycosides derived from A. discolorA. discolor, a , a plant used in traditional Peruvian plant used in traditional Peruvian medicine, reduce withdrawal medicine, reduce withdrawal symptoms in morphine-dependent symptoms in morphine-dependent individuals (Capasso 1998).individuals (Capasso 1998).

• Need replication with controlled Need replication with controlled trialtrial

ExerciseExercise• Chronic alcoholics frequently experience Chronic alcoholics frequently experience

depressed mood, which may trigger depressed mood, which may trigger increased drinking. increased drinking.

• Alcoholics who exercised daily while Alcoholics who exercised daily while hospitalized for medical monitoring during hospitalized for medical monitoring during acute detoxification reported significant acute detoxification reported significant improvements in general emotional well-improvements in general emotional well-being (Palmer, Vacc, & Epstein, 1988). being (Palmer, Vacc, & Epstein, 1988).

• Abstinent alcoholics enrolled in outpatient Abstinent alcoholics enrolled in outpatient recovery programs report improved mood recovery programs report improved mood with regular strength training or aerobic with regular strength training or aerobic exercise (Palmer, Palmer, Michiels, & exercise (Palmer, Palmer, Michiels, & Thigpen, 1995; Skrede et al 2006). Thigpen, 1995; Skrede et al 2006).

Exercise—bottom lineExercise—bottom line

• Because of demonstrated mental Because of demonstrated mental health benefits regular exercise health benefits regular exercise should be should be strongly encouragedstrongly encouraged in in all patients who abuse alcohol and all patients who abuse alcohol and drugs (ie, assuming the absence of drugs (ie, assuming the absence of medical problems aggrivated by medical problems aggrivated by physical activity).physical activity).

Mindfulness trainingMindfulness training

• Mindfulness training is widely offered in drug and Mindfulness training is widely offered in drug and alcohol relapse prevention programs and alcohol relapse prevention programs and probably reduces the risk of relapse (Breslin, probably reduces the risk of relapse (Breslin, Curtis, Zack, Martin, McMain, & Shelley, 2002). Curtis, Zack, Martin, McMain, & Shelley, 2002).

• Two studies suggest that Transcendental Two studies suggest that Transcendental meditation (TM) may be especially effective in meditation (TM) may be especially effective in reducing the relapse risk in abstinent alcoholics reducing the relapse risk in abstinent alcoholics (Alexander, Robinson, & Rainforth, 1994; (Taub, (Alexander, Robinson, & Rainforth, 1994; (Taub, Steiner, Weingarten, & Walton, 1994). Steiner, Weingarten, & Walton, 1994).

• Twelve-step programs that emphasize a Twelve-step programs that emphasize a particular religious or spiritual philosophyparticular religious or spiritual philosophy maymay be more effective than “spiritually neutral” be more effective than “spiritually neutral” programs (Muffler, Langrod, & Larson, 1991). programs (Muffler, Langrod, & Larson, 1991).

Virtual reality graded exposure Virtual reality graded exposure therapy (VRGET)therapy (VRGET)

• VRGET clinical applications include PTSD, VRGET clinical applications include PTSD, phobias, eating disorders, cognitive phobias, eating disorders, cognitive rehabilitation following stroke, and rehabilitation following stroke, and substance abuse and dependence. substance abuse and dependence.

• VRGET protocols stimulating drug or VRGET protocols stimulating drug or alcohol craving are coupled with response alcohol craving are coupled with response prevention and desensitization. prevention and desensitization.

• Regular VRGET sessions diminish nicotine Regular VRGET sessions diminish nicotine or illicit drug craving in real life situations or illicit drug craving in real life situations expected to trigger craving. expected to trigger craving.

VGRET for nicotine cravingVGRET for nicotine craving

• 20 nicotine-dependent adults not taking 20 nicotine-dependent adults not taking conventional anti-craving medications were conventional anti-craving medications were exposed to virtual smoking cues resulting in exposed to virtual smoking cues resulting in increased nicotine craving and physiologic increased nicotine craving and physiologic indicators of craving including elevated indicators of craving including elevated pulse and respiration rate (Bordnick 2004) . pulse and respiration rate (Bordnick 2004) .

• Subjects exposed to Subjects exposed to neutralneutral VR stimuli in the VR stimuli in the sham arm did not report increased nicotine sham arm did not report increased nicotine craving.craving.

Future VR toolsFuture VR tools

• Other VR environments are being developed to Other VR environments are being developed to stimulate alcohol or marijuana craving. stimulate alcohol or marijuana craving.

• Future VR tools will be combined with cognitive Future VR tools will be combined with cognitive therapy strategies aimed at response prevention and therapy strategies aimed at response prevention and desensitization to real life situations that would be desensitization to real life situations that would be expected to stimulate craving or drug-seeking expected to stimulate craving or drug-seeking behavior. behavior.

• Future VR tools will use increasingly realistic virtual Future VR tools will use increasingly realistic virtual cues with the goal of desensitizing alcoholics and cues with the goal of desensitizing alcoholics and drug abusers to environments expected to stimulate drug abusers to environments expected to stimulate craving or drug-using behavior. craving or drug-using behavior.

• A A virtual crack housevirtual crack house is currently under development is currently under development at the University of Georgia.at the University of Georgia.

Cranioelectrotherapy stimulation Cranioelectrotherapy stimulation (CES)(CES)

• CES involves the application of weak electrical CES involves the application of weak electrical current to specific points on the scalp or ears. current to specific points on the scalp or ears.

• In a 7-year prospective study of CES in the In a 7-year prospective study of CES in the treatment of alcohol, drug, and nicotine treatment of alcohol, drug, and nicotine addiction, acute and chronic withdrawal addiction, acute and chronic withdrawal symptoms were diminished, normal sleep symptoms were diminished, normal sleep patterns were restored more rapidly, and patterns were restored more rapidly, and more patients remained addiction-free more patients remained addiction-free following regular CES treatments compared following regular CES treatments compared with conventional medication management. with conventional medication management.

CES (2)CES (2)

• CES-treated patients reported significantly CES-treated patients reported significantly fewer anxiety symptoms and higher quality of fewer anxiety symptoms and higher quality of life measures compared with patients who life measures compared with patients who underwent conventional drug treatments underwent conventional drug treatments (Patterson, Firth, & Gardiner, 1984). (Patterson, Firth, & Gardiner, 1984).

• Protocols that use daily CES treatments Protocols that use daily CES treatments compare favorably with combined compare favorably with combined psychotherapy, relaxation training and psychotherapy, relaxation training and biofeedback for reducing anxiety in patients biofeedback for reducing anxiety in patients abusing any substance (Overcash & abusing any substance (Overcash & Siebenthall, 1989).Siebenthall, 1989).

CES (3)CES (3)

• Daily 30-minute CES treatments Daily 30-minute CES treatments significantly improve cognitive functioning significantly improve cognitive functioning and reduce measures of stress and anxiety and reduce measures of stress and anxiety in inpatient alcoholics or poly-substance in inpatient alcoholics or poly-substance abusers (Schmitt, Capo, & Boyd, 1986). abusers (Schmitt, Capo, & Boyd, 1986).

• In a 4-week double-blind study, 20 In a 4-week double-blind study, 20 depressed alcoholics randomized to daily depressed alcoholics randomized to daily CES treatments (70 to 80 Hz, 4 to 7 mA), CES treatments (70 to 80 Hz, 4 to 7 mA), versus sham treatments reported versus sham treatments reported significantly reduced anxiety by the end of significantly reduced anxiety by the end of the study. the study.

CES—bottom lineCES—bottom line

• CES may be a reasonable alternative CES may be a reasonable alternative treatment of anxiety in withdrawing treatment of anxiety in withdrawing alcoholics or substance abusers while alcoholics or substance abusers while avoiding the risks of cross-tolerance avoiding the risks of cross-tolerance and dependence associated with and dependence associated with benzodiazepine use in this population benzodiazepine use in this population (Krupitsky, Burakov, Karandashova, (Krupitsky, Burakov, Karandashova, 1991).1991).

EEG and EMG biofeedback trainingEEG and EMG biofeedback training

• Limited data suggest that EMG and thermal Limited data suggest that EMG and thermal biofeedback (Sharp 1997) as well as EEG biofeedback (Sharp 1997) as well as EEG biofeedback training may reduce relapse risk in biofeedback training may reduce relapse risk in abstinent alcoholics (Peniston 1989; Peniston 1990). abstinent alcoholics (Peniston 1989; Peniston 1990).

• In EEG biofeedback training the patient learns how In EEG biofeedback training the patient learns how to self-induce brain states corresponding to deep to self-induce brain states corresponding to deep relaxation. relaxation.

• Case studies Case studies suggestsuggest that EEG biofeedback using that EEG biofeedback using an alpha-theta entrainment protocol reduces relapse an alpha-theta entrainment protocol reduces relapse risk in abstinent alcoholics (Schneider 1993), but risk in abstinent alcoholics (Schneider 1993), but notnot in abstinent cocaine abusersin abstinent cocaine abusers (Richard 1995). (Richard 1995).

Dim morning lightDim morning light

• Early morning exposure to dim light (ie, narrow-Early morning exposure to dim light (ie, narrow-spectrum light with an intensity of 250 lux) spectrum light with an intensity of 250 lux) improves depressed mood in abstinent alcoholics improves depressed mood in abstinent alcoholics diagnosed with Seasonal Affective Disorder diagnosed with Seasonal Affective Disorder (Avery 1998). (Avery 1998).

• Depressed mood is an established risk factor for Depressed mood is an established risk factor for alcohol relapse, and alcohol relapse, and mood enhancing effects mood enhancing effects of early morning dim light may reduce of early morning dim light may reduce relapse risk in abstinent alcoholics with relapse risk in abstinent alcoholics with SAD.SAD.

• Findings are preliminary. More research is Findings are preliminary. More research is needed.needed.

Acupuncture for reducing alcohol Acupuncture for reducing alcohol cravingcraving

• Regular acupuncture treatments increase brain Regular acupuncture treatments increase brain levels of endogenous opioid peptides (Cheng, levels of endogenous opioid peptides (Cheng, Pomeranz, & Yu, 1980; Clement-Jones, Pomeranz, & Yu, 1980; Clement-Jones, McLoughlin, Lowry, Besser, Rees, & Wen, 1979.McLoughlin, Lowry, Besser, Rees, & Wen, 1979.

• Stimulating specific acupuncture points on the Stimulating specific acupuncture points on the ears, hands, and the back of the neck may ears, hands, and the back of the neck may reduce alcohol craving and decrease reduce alcohol craving and decrease withdrawal symptoms in alcoholics however withdrawal symptoms in alcoholics however acupuncture probably does acupuncture probably does notnot reduce craving reduce craving and relapse after treatment is discontinued and relapse after treatment is discontinued (Konefal, Duncan, & Clemence, 1994; Richard, (Konefal, Duncan, & Clemence, 1994; Richard, Montoya, Nelson, & Spence, 1995).Montoya, Nelson, & Spence, 1995).

Acupuncture for relapse Acupuncture for relapse prevention in abstinent prevention in abstinent alcoholicsalcoholics• Findings are inconsistent for acupuncture in Findings are inconsistent for acupuncture in

relapse prevention in abstinent alcoholics possibly relapse prevention in abstinent alcoholics possibly reflecting different treatment protocols (i.e., reflecting different treatment protocols (i.e., conventional vs. electroacupuncture), differences conventional vs. electroacupuncture), differences in frequency or duration of treatment, and the in frequency or duration of treatment, and the skill level or specialized training of practitioners. skill level or specialized training of practitioners.

• In one sham-controlled study, alcoholics reported In one sham-controlled study, alcoholics reported significant reductions in withdrawal symptoms significant reductions in withdrawal symptoms within hours of the initial treatment and no within hours of the initial treatment and no withdrawal symptoms within 72 hours of the withdrawal symptoms within 72 hours of the second acupuncture treatment (Yankovskis, second acupuncture treatment (Yankovskis, Beldava, & Livina, 2000). Beldava, & Livina, 2000).

Acupuncture for alcohol craving Acupuncture for alcohol craving and relapse preventionand relapse prevention

• Another sham controlled study showed no Another sham controlled study showed no benefit of acupuncture re reduced craving benefit of acupuncture re reduced craving or relapse risk in alcoholics (Worner, or relapse risk in alcoholics (Worner, Zeller, Schwartz, Zwas, & Lyon, 1992).Zeller, Schwartz, Zwas, & Lyon, 1992).

• HoweverHowever…..some evidence that specific …..some evidence that specific acupuncture protocols significantly acupuncture protocols significantly reduced alcohol craving and reduced reduced alcohol craving and reduced relapse risk in recovering alcoholics relapse risk in recovering alcoholics (Bullock, Culliton, & Olander, 1989; (Bullock, Culliton, & Olander, 1989; Bullock, Umen, Culliton, & Olander, 1987).Bullock, Umen, Culliton, & Olander, 1987).

Acupuncture for smoking Acupuncture for smoking cessation and nicotine withdrawalcessation and nicotine withdrawal

• Most controlled trials on smoking are negative Most controlled trials on smoking are negative or equivocal but acupuncture is widely used in or equivocal but acupuncture is widely used in the U.S. and western Europe to facilitate the U.S. and western Europe to facilitate smoking cessation and lessen symptoms of smoking cessation and lessen symptoms of nicotine withdrawal.nicotine withdrawal.

• Initial open trials of acupuncture for smoking Initial open trials of acupuncture for smoking cessation were very promising (Fuller, 1982)cessation were very promising (Fuller, 1982)

• Recent sham-controlled trials were equivocal. Recent sham-controlled trials were equivocal. No significant differences in severity of No significant differences in severity of withdrawal symptoms in nicotine-dependent withdrawal symptoms in nicotine-dependent patients given accepted electroacupuncture patients given accepted electroacupuncture protocol versus sham (White, Resch, & Ernst, protocol versus sham (White, Resch, & Ernst, 1998).1998).

Auricular acupuncture for nicotine Auricular acupuncture for nicotine craving and smoking cessationcraving and smoking cessation

• High school student smokers randomized High school student smokers randomized to weekly auricular acupuncture to weekly auricular acupuncture treatments using well defined protocol for treatments using well defined protocol for reducing smoking versus a non-specific reducing smoking versus a non-specific protocol. protocol.

• By 4-weeks only one student had stopped By 4-weeks only one student had stopped smoking and there no significant smoking and there no significant differences in nicotine craving however differences in nicotine craving however students who completed the smoking students who completed the smoking cessation protocol smoked fewer cessation protocol smoked fewer cigarettes per day compared to the sham cigarettes per day compared to the sham group (Kang, Shin, Kim & Youn, 2005).group (Kang, Shin, Kim & Youn, 2005).

Acupuncture for smoking Acupuncture for smoking cessation and nicotine withdrawalcessation and nicotine withdrawal

• A Cochrane systematic review and meta-A Cochrane systematic review and meta-analysis of 22 sham-controlled studies and analysis of 22 sham-controlled studies and more than 2,000 patients on the efficacy of more than 2,000 patients on the efficacy of acupuncture for smoking cessation, found no acupuncture for smoking cessation, found no evidence for therapeutic acupuncture for evidence for therapeutic acupuncture for smoking cessation. smoking cessation.

• Sham-controlled studies on conventional Sham-controlled studies on conventional acupuncture, acupressure, electroacupuncture, acupuncture, acupressure, electroacupuncture, and laser acupuncture were included in the and laser acupuncture were included in the meta-analysis (White, Rampes, & Ernst, 2004). meta-analysis (White, Rampes, & Ernst, 2004).

Acupuncture for smoking Acupuncture for smoking cessation—bottom linecessation—bottom line

• Longer and larger sham-controlled Longer and larger sham-controlled studies are needed to determine studies are needed to determine both the optimum protocol, both the optimum protocol, frequency, duration and type of frequency, duration and type of acupuncture treatment for smoking acupuncture treatment for smoking cessation.cessation.

Acupuncture for nicotine Acupuncture for nicotine withdrawal and cocaine addictionwithdrawal and cocaine addiction• A Cochrane systematic review and a separate A Cochrane systematic review and a separate

independent review concluded that both independent review concluded that both conventional acupuncture and conventional acupuncture and electroacupuncture are electroacupuncture are equally ineffectiveequally ineffective in in reducing symptoms of nicotine withdrawal and reducing symptoms of nicotine withdrawal and controlling cocaine addiction (D’Alberto, 2004; controlling cocaine addiction (D’Alberto, 2004; White,1996). White,1996).

• HoweverHowever….….cocaine abusers frequently cocaine abusers frequently report subjective calming and diminished report subjective calming and diminished cravingcraving after only one or two acupuncture after only one or two acupuncture treatments, and this effect is sustained with treatments, and this effect is sustained with repeated treatments.repeated treatments.

• More studies neededMore studies needed

Acupuncture for cocaine Acupuncture for cocaine addictionaddiction

• 8-week placebo-controlled study comparing 8-week placebo-controlled study comparing acupuncture with conventional drug therapies acupuncture with conventional drug therapies in cocaine addicts on methadone in cocaine addicts on methadone maintenance therapy 50% dropped out, but maintenance therapy 50% dropped out, but 90% of those who completed the study 90% of those who completed the study achieved abstinence following 8 weeks achieved abstinence following 8 weeks of treatmentof treatment (Margolin, Avants, chang, & (Margolin, Avants, chang, & Posten, 1993). Posten, 1993).

• Patients who achieved abstinence reported Patients who achieved abstinence reported diminished narcotics craving and improved diminished narcotics craving and improved mood (White 1996)mood (White 1996)

Auricular acupuncture for Auricular acupuncture for cocaine addictioncocaine addiction

• Three auricular acupuncture protocols Three auricular acupuncture protocols widely used for relapse prevention in widely used for relapse prevention in cocaine abusers were cocaine abusers were equally effectiveequally effective in reducing craving regardless of protocol in reducing craving regardless of protocol (Konefal, Duncan, & Clemence, 1995).(Konefal, Duncan, & Clemence, 1995).

• Beneficial outcomes may result from a Beneficial outcomes may result from a general effectgeneral effect –more studies needed –more studies needed

Qigong and heroin addictionQigong and heroin addiction

• Findings of sham-controlled trials suggest Findings of sham-controlled trials suggest that external qigong treatments reduce the that external qigong treatments reduce the severity of withdrawal symptoms in heroin severity of withdrawal symptoms in heroin addicts (Li 2002). addicts (Li 2002).

• Animal studies suggest that external qigong Animal studies suggest that external qigong applied to morphine-dependent mice applied to morphine-dependent mice lessens the behavioral symptoms of lessens the behavioral symptoms of withdrawal following pharmacological withdrawal following pharmacological blockade of morphine at the level of brain blockade of morphine at the level of brain receptors (Zhixian 2003). receptors (Zhixian 2003).

Qigong in management of Qigong in management of narcotics withdrawalnarcotics withdrawal

• Regular qigong treatments may provide a Regular qigong treatments may provide a useful adjunct to conventional pharmacological useful adjunct to conventional pharmacological and behavioral management of detoxification and behavioral management of detoxification and withdrawal from heroin and other opiates. and withdrawal from heroin and other opiates.

• The The unskillful practice of qigong can unskillful practice of qigong can potentially result in agitation or potentially result in agitation or psychosispsychosis..

• Addicts interested in qigong should work with a Addicts interested in qigong should work with a skilled qigong instructor or medical skilled qigong instructor or medical qigong therapistqigong therapist..