In the first part of this column (Psychiatric Times, February 2007), I reviewed treatments whose beneficial effects are probably achieved through a discrete biological or pharmacological mechanism of action. These included dietary modifications; supplementation with specific vitamins, minerals, and amino acids; and medicinal herbs. In this part, I will review the evidence for approaches that reduce the risk of relapse, diminish craving, or mitigate withdrawal symptoms but for which there is no evidence for direct biological or pharmacological effect. These include exercise, mindfulness training, virtual reality graded exposure therapy (VRGET), cranio- electrotherapy stimulation (CES), dim light exposure,electroencephalogram (EEG) and electromyogram biofeedback, acupuncture, and qigong. Persons receiving conventional pharmacological treatments that seek to reduce the risk of relapse, diminish craving, and mitigate withdrawal symptoms may safely use these and other nonbiological therapies.
Persons who chronically abuse alcohol frequently experience depressed mood, which may trigger increased drinking. Those who exercised daily while hospitalized for medical monitoring during acute detoxification of alcohol reported significant improvements in general emotional well-being.1 Persons abstaining from alcohol use who were enrolled in outpatient recovery programs reported improved mood with regular strength training or aerobic exercise.2,3 Because of its demonstrated mental health benefits, regular exercise should be encouraged in all patients who abuse alcohol and drugs (assuming that there are no medical problems that would be aggravated by physical activity).
Mindfulness training is offered widely in drug and alcohol relapse prevention programs and may reduce the risk of relapse in persons with substance use disorders.4 Two studies suggest that transcendental meditation may be espe- cially effective in reducing the relapse rate in persons who abstain from alcohol.5,6 One study found that 12-step programs that emphasize a particular religious or spiritual philosophy may be more effective than "spiritually neutral" programs.7
Virtual reality graded exposure
VRGET is a rapidly emerging technological intervention with a wide range of promising clinical applications for psychiatric disorders, including posttraumatic stress disorder, phobias, eating disorders, cognitive rehabilitation following stroke, and substance abuse and dependence. Most virtual reality tools are in the early stages of development and are not commercially available. VRGET protocols have been created with the goal of stimulating drug or alcohol craving in patients followed by response prevention and desensitization.
Regular VRGET sessions result in diminished nicotine or illicit drug cravings in real-life situations that would be expected to trigger craving. In a small controlled trial, 20 nicotine-dependent adults who were not taking conventional anticraving medications were enrolled in a VRGET protocol.8 The patients were exposed to virtual smoking cues that resulted in increased nicotine craving and physiological indicators of craving, including elevated pulse and respiration rates. Subjects exposed to neutral virtual reality stimuli in the sham arm did not report symptoms of increased nicotine craving.
Other virtual reality environments are being developed to stimulate alcohol or marijuana craving, and future virtual reality tools will be combined with cognitive therapy strategies aimed at response prevention and desensitization to real-life situations that would be expected to stimulate craving or drug-seeking behavior. Future VRGET tools will couple cognitive therapy with increasingly realistic virtual cues to achieve the goal of desensitizing persons who abuse alcohol or drugs to environments that would be expected to stimulate craving or drug-using behavior. A significant emerging virtual reality tool is the "virtual crack house," which is currently under development at the University of Georgia.
1. Palmer J, Vacc N, Epstein J. Adult inpatient alcoholics: physical exercise as a treatment intervention. J Stud Alcohol. 1988;49:418-421.
2. Palmer JA, Palmer LK, Michiels K, Thigpen B. Effects of type of exercise on depression in recovering substance abusers. Percept Mot Skills. 1995;80:523-530.
3. Skrede A, Munkvold H, Watne O, Martinsen EW. Exercise contacts in the treatment of substance dependence and mental disorders [in Norwegian]. Tidsskr Nor Laegeforen. 2006;126:1925-1927.
4. Breslin FC, Zack M, McMain S. An information-processing analysis of mindfulness: implications for relapse prevention in the treatment of substance abuse. Clinical Psychology: Science and Practice. 2002;9:275-299.
5. Alexander CP, Robinson P, Rainforth M. Treating and preventing alcohol, nicotine, and drug abuse through transcendental meditation: a review and statistical meta-analysis. Alcohol Treat Q. 1994;11:13-87.
6. Taub E, Steiner SS, Weingarten E, Walton KG. Effectiveness of broad spectrum approaches to relapse prevention in severe alcoholism: a long-term, randomized controlled trial of transcendental meditation, EMG biofeedback and electronic neurotherapy. Alcohol Treat Q. 1994;11:187-220.
7. Muffler J, Langrod J, Larson D. There is a balm in Gilead: religion and substance abuse treatment. In: Lowinson JH, Ruiz P, Millman RB, eds. Substance Abuse: A Comprehensive Textbook. 2nd ed. Baltimore: Williams & Wilkins; 1992.
8. Bordnick PS, Graap KM, Copp H, et al. Utilizing virtual reality to standardize nicotine craving research: a pilot study. Addict Behav. 2004;29:1889-1894.
9. Patterson MA, Firth J, Gardiner R. Treatment of drug, alcohol and nicotine addiction by neuroelectric therapy: analysis of results over 7 years. Journal of Bioelectricity. 1984;3:193-221.
10. Overcash S, Siebenthall A. The effects of cranial electrotherapy stimulation and multisensory cognitive therapy on the personality and anxiety levels of substance abuse patients. Am J Electromed. 1989;6:105-111.
11. Schmitt R, Capo T, Boyd E. Cranial electrotherapy stimulation as a treatment for anxiety in chemically dependent persons. Alcohol Clin Exp Res. 1986;10: 158-160.
12. Krupitsky EM, Burakov AM, Karandashova GF, et al. The administration of transcranial electric treatment for affective disturbances therapy in alcoholic patients. Drug Alcohol Depend. 1991;27:1-6.
13. Sharp C, Hurford DP, Allison J, et al. Facilitation of internal locus of control in adolescent alcoholics through a brief biofeedback-assisted autogenic relaxation training procedure. J Subst Abuse Treat. 1997;14:55-60.
14. Peniston EG, Kulkosky PJ. Alpha-theta brainwave training and beta-endorphin levels in alcoholics. Alcohol Clin Exp Res. 1989;13:271-279.
15. Peniston EG, Kulkosky PJ. Alcoholic personality and alpha-theta brainwave training. Med Psychother. 1990;3: 37-55.
16. Schneider F, Elbert T, Heimann H, et al. Self-regulation of slow cortical potentials in psychiatric patients: alcohol dependency. Biofeedback Self Regul. 1993;18: 23-32.
17. Richard AJ, Montoya ID, Nelson R, Spence RT. J Subst Abuse Treat. 1995;12:401-413.
18. Avery DH, Bolte MA, Ries R. Dawn simulation treatment of abstinent alcoholics with winter depression. J Clin Psychiatry. 1998;59:36-42.
19. Brewington V, Smith M, Lipton D. Acupuncture as a detoxification treatment: an analysis of controlled research. J Subst Abuse Treat. 1994;11:289-307.
20. Cheng RS, Pomeranz B, Yu G. Electroacupuncture treatment of morphine-dependent mice reduces signs of withdrawal, without showing cross-tolerance. Eur J Pharmacol. 1980;68:477-481.
21. Clement-Jones V, McLoughlin L, Lowry PJ, et al. Acupuncture in heroin addicts; changes in Metenkephalin and beta-endorphin in blood and cerebrospinal fluid. Lancet. 1979;2:380-383.
22. Ng LK, Douthitt TC, Thoa NB, Albert CA. Modification of morphine-withdrawal syndrome in rats following transauricular electrostimulation: an experimental paradigm for auricular electroacupuncture. Biol Psychiatry. 1975;10:575-580.
23. Konefal J, Duncan R, Clemence C. The impact of the addition of an acupuncture treatment program to an existing metro-Dade County outpatient substance abuse treatment facility. J Addict Dis. 1994;13:71-99.
24. Richard AJ, Montoya ID, Nelson R, Spence RT. Effectiveness of adjunct therapies in crack cocaine treatment. J Subst Abuse Treat. 1995;12:401-413.
25. Yankovskis G, Beldava I, Livina B. Osteoreflectory treatment of alcohol abstinence syndrome and craving for alcohol in patients with alcoholism. Acupunct Electrother Res. 2000;25:9-16.
26. Bullock ML, Culliton PD, Olander RT. Controlled trial of acupuncture for severe recidivist alcoholism. Lancet. 1989;24:1435-1439.
27. Bullock ML, Umen AJ, Culliton PD, Olander RT. Acupuncture treatment of alcoholic recidivism: a pilot study. Alcohol Clin Exp Res. 1987;11:292-295.
28. Worner TM, Zeller B, Schwarz H, et al. Acupuncture fails to improve treatment outcome in alcoholics. Drug Alcohol Depend. 1992;30:169-173.
29. Fuller JA. Smoking withdrawal and acupuncture. Med J Aust. 1982;1:28-29.
30. White AR, Resch KL, Ernst E. Randomized trial of acupuncture for nicotine withdrawal symptoms. Arch Intern Med. 1998;158:2251-2255.
31. Kang HC, Shin KK, Kim KK, Youn BB. The effects of the acupuncture treatment for smoking cessation in high school student smokers. Yonsei Med J. 2005;46: 206-212.
32. White AR, Rampes H, Ernst E. Acupuncture for smoking cessation. Cochrane Database Syst Rev. 2002;2: CD000009.
33. D'Alberto A. Auricular acupuncture in the treatment of cocaine/crack abuse: a review of efficacy, the use of the National Acupuncture Detoxification Association protocol, and the selection of sham points. J Altern Complement Med. 2004;10:985-1000.
34. White AR, Resch KL, Ernst E. A meta-analysis of acupuncture techniques for smoking cessation. Tob Control. 1999;8:393-397.
35. Konefal J, Duncan R, Clemence C. Comparison of three levels of auricular acupuncture in an outpatient substance abuse treatment program. Altern Med J. 1995;2:8-17.
36. Margolin A, Avants SK, Chang P, Kosten TR. Acupuncture for the treatment of cocaine dependence in methadone-maintained patients. Am J Addict. 1993;2: 194-201.
37. Li M, Chen K, Mo Z. Use of qigong therapy in the detoxification of heroin addicts. Altern Ther Health Med. 2002;8:56-59.
38. Mo Z, Chen KW, Ou W, Li M. Benefits of external qigong therapy on morphine-abstinent mice and rats. J Altern Complement Med. 2003;9:827-835.