Abstract
Integrative Treatment Plan
Few chronic conditions in life are solved by one treatment modality. When viewing opioid addiction as a chronic condition, one sees the need for a comprehensive and integrative treatment plan. 1 People who are opioid addicted are often in a complex milieu of biochemical and environmental influences that have led to their addiction and frequently have comorbid conditions and other addictions. Therefore, a treatment plan that takes all of these complexities under consideration and addresses the mind, body, and spirit is, in many cases, necessary for lasting change.
For example, chronic pain, stress, and anxiety are common comorbid conditions in people with opioid addictions. Fortunately, these are conditions for which complementary therapies can be very effective in helping to address and improve symptoms. Along with a conventional approach, utilization of complementary therapies such as massage, mindfulness-based therapies, yoga, acupuncture, and others can help address some of the hidden and root causes of addiction.
In fact, one survey of more than 900 patients using opioids for chronic pain found that in excess of 40% of opioid users had utilized a complementary and alternative medicine (CAM) therapy during the previous year. 2 Massage therapy and chiropractic were the most commonly used treatments. This shows us that people who take opioids are interested in CAM. Of greatest interest in this particular survey is the fact that 90% reported that massage helped them and 80% reported that chiropractic and yoga were beneficial as well. The authors caution that this study did not determine if such therapies lower opioid use. However, they stated that this raises important questions about the important role that CAM may play in the health of people who use opioids.
When referring people to integrative and complementary practitioners, it is important that people who are addicted to opioids work with clinicians and practitioners who are well versed in both addiction and integrative medicine treatment for the best outcomes. It is also important—on our medical system change agenda—that such integrative treatment approaches are made available and accessible to all people within a wide range of socioeconomic backgrounds.
References
Clinical Instructor, Internal Medicine
Case Western Reserve University School of Medicine
Cleveland, OH
Complementary and Alternative Medicine
The prevalence rates of opioid use disorders (OUDs) have increased dramatically over the last 10 years, related mostly to the use of prescription opioids for chronic pain treatment. 1 In clinical practice, interdisciplinary rehabilitation programs are among the most effective approaches that are commonly used in managing OUDs, especially among patients suffering from chronic pain. 2
Cognitive–behavioral therapy (CBT) is a common component of such programs. 2 CBT is short term, usually provided as a 3- to 12-week intervention either in groups or in individual therapy. 3 CBT helps patients with several aspects essential to successful treatment of opioid addiction, including management of pain, coping skills, reinforcement contingencies, motivation for abstinence, and improved interpersonal functioning. 3 Patients with OUDs usually experience destructive, negative thinking and depression. 4 CBT allows patients to identify harmful thought patterns that lead to self-destructive actions and seek alternate thinking that may help prevent drug-seeking behavior or relapse. 5
Mindfulness meditation is another component of rehabilitation programs. It is used to train nonjudgmental awareness and attention to present-moment experience. Although more rigorous studies are still needed to confirm efficacy, current research suggests that mindfulness meditation may increase the parasympathetic nervous system response, decrease sympathetic nervous system activity, attenuate the effects of stress, and increase self-efficacy. 6 The Mindfulness-Based Relapse Prevention Program (MBRP) consists of eight two-hour sessions, each including formal mindfulness practices, exercises, and skills designed to bring these practices into high-risk situations that trigger drug craving or relapse. 5 These sessions help patients learn how to overpower these triggers and choose a more skillful response. 5
Based on clinical practice and literature, there is no single intervention that is superior to the other. Interdisciplinary rehabilitation programs that integrate mindfulness meditation with CBT provide long-term changes in improved well-being, self-esteem, and personal empowerment. 6,7
References
Canadian College of Naturopathic Medicine
Toronto, Canada
Yoga Therapy
The critical need for an alternative to opioids for pain control has led to the emergence of yoga as a viable option. Emerging scientific evidence points toward the usefulness of yoga intervention in pain and substance abuse. Yoga increases endogenous opioids (β-endorphins), 1 reduces adrenocorticotropic hormone and cortisol levels, increases gamma-aminobutyric acid levels in the brain, and increases oxytocin. 2 This may help in the regulation of pain, pleasure, stress, and mood, 3 thereby contributing toward the management of opioid withdrawal symptoms and the attenuation of relapse. Abnormal connectivity in default mode network was observed in opioid use disorder (OUD) patients and the same has been shown to improve with yoga. 3,4 Yoga has also been found to be useful in enhancing prefrontal activation, reducing impulsivity and promoting positive behavioral changes with better self-regulation. 5,6 Thus, yoga therapy, a low-cost and low-risk adjunct, may be used to improve overall quality of life and reduce substance use among OUD patients.
Based on our clinical experience of more than two decades and available scientific evidence, the following yoga module may be considered useful for patients suffering from opioid dependence (total duration: 60 minutes):
Warm-up (10 minutes): loosening of joints (toes, ankles, knees, hips, fingers, wrists, shoulders, and neck), hands in and out breathing, twisting, side bending, forward-backward bending, tiger stretch breathing.
Sun salutations (Suryanamaskara; 5 minutes): seven rounds—three slow, four fast.
Guided relaxation (tightening and loosening of body parts sequentially from toe to head; 5 minutes) in corpse pose (Shavasana).
Physical postures (Asanas; 15 minutes): Standing: tree pose (Vrikshasana); sitting: butterfly pose (Patangasana), forward leg hold and rock pose (Shishupalasana); prone: cobra pose (Bhujangasana), boat pose stretch with breath synchronization (Navasana), crocodile stretch pose (Makarasana); Supine: bridge pose (Setubandhasana), wind releasing pose (Pavanmuktasana Kriya).
Relaxation with abdominal breathing in corpse pose (Shavasana; 3 minutes): deep abdominal breathing in 1:3 ratio (i.e., one part inhalation to three parts exhalation).
Regulated breathing (Pranayama; 10 minutes): bellow's breath (Bhastrika; 3 minutes: three cycles of 20 breaths each), humming bee breath (Bhramari; 2 minutes), left nostril breathing (Chandra-Anuloma Viloma Pranayama; 2 minutes), alternate nostril breathing (Nadishuddhi Pranayama; 3 minutes).
Relaxation (12 minutes): OM chanting (2 minutes) followed by deep relaxation with a positive affirmation (“I am healthy, happy, and satisfied”) in corpse pose (Shavasana; 10 minutes).
Acknowledgments
The authors acknowledge Department of Science and Technology, Science and Technology of Yoga and Meditation (DST-SATYAM) Scheme, Government of India, for funding research on yoga for opioid dependence syndrome.
References
Department of Psychiatry
NIMHANS Integrated Centre for Yoga
Bangalore, India
Division of Life Sciences
Swami Vivekananda Yoga University
Bangalore, India
Department of Psychiatry
NIMHANS Integrated Centre for Yoga
Bangalore, India
For this interactive feature column, Clinical Roundup, a new question is posed and then answered by experts in the field. In the next issue, the Clinical Roundup will continue with how you treat opioid addiction in your practice.