Addictions and Recovery

Kitzman, et. al. (2023) make an interesting statement in their article which specifically pertains to acupuncture:

“Treatment plans in addiction medicine, which conventionally center around pharmacologic and psychosocial interventions, remain insufficient or unavailable, especially for adolescents and young adults“.

However, if you think about it, there are other treatment alternatives, collectively called Complementary and Alternative Medicine (CAM) which do not involve drug-assisted treatment programs. Complementary and alternative medicine (CAM) practices include acupuncture, hypnotherapy, herbal medicine, mindfulness, music therapy and yoga (Walia, et. al., 2021) and have a place in the treatment of diseases. In this blog, I will discuss the use of acupuncture, guided imagery, and yoga for the treatment of substance use disorders, because each of these can address various aspects of treatment, including detoxification, and the reduction of anxiety, sleep disorders, and craving, all of which are risk factors for relapse.

I. Acupuncture

A. What it is

The following is an excerpt from an earlier post, https://addictionsandrecoverydotblog.com/2024/07/19/31-acupuncture-as-a-detox-and-treatment-modality/ —

Acupuncture as a detoxification modality is based on modern-day adaptations of 3,000 year-old practices in Chinese medicine (Brumbaugh, 1994).   Describing the procedure that are used and trying to explain the reasons why it works requires a lingo that is quite unusual by Western allopathic standards.

To a practitioner of Oriental medicine, the success of acupuncture as a treatment modality is based on the concept of “Chi”. In Oriental medicine, Chi refers to the life force that imbues each living person. It is allotted at birth, and is gone when you die. There are two forms of Chi, including Ancestral Chi, which is genetically-based and given at birth, and Jing, which is the energy of growth. The essential life energy of Chi circulates throughout body on a 24-hour cycle through 12 basic & 2 central channels. Drugs burn up the liver, which is a source of shen, and leads to anger.

            It is assumed that stimulation of certain points on the surface of the body could cure or relieve diseases by affecting certain internal organs.  The sensations evoked by stimulation on the surface of the skin always traveled to other parts along definite routes, called meridians.  These meridians, distributed symmetrically over the human body, are considered the conduits for flow of “Qi” (chi) and connect internal viscera with external skin and sense organs.   There are 12 major meridians, corresponding to the twelve “organs”, eight “extra meridians”, called collaterals, as well as a network of minor meridians.

           

According to Dr. Michael Smith, “the intense and frequent abuse of chemical substances damages the Jing-essence.”  The kidney, which is the organ which stores this quality of Jing becomes damaged, so that Jing becomes depleted, and the individual becomes Yin – deficient, so the patient shows the signs of “empty fire syndrome”, manifested by undirected and unchanneled anger and resentment (Brumbaugh, 1994).  The symptoms associated with premature aging, including stooped posture, decaying teeth, graying hair, and a sunken look about the eyes, are all indicative of Jing-depletion.  Will you find any mention of “empty fire syndrome” as a manifestation of alcohol abuse in any Western medical textbook?  No, I don’t think so.  However, does the term serve as an eloquent metaphor of the consequences of alcohol abuse?  Absolutely.

In 1955, the French physician Paul Nogier found that all traditional Chinese meridians were accessible via the ear, so that ear reflects entire body. The ear is in the shape of an upside-down human being, and has 150 points, corresponding to each of the points in the body. Applying pressure onto selected points with acupuncture needles elicits an effect which restores the proper balance of energy. The specific points which are stimulated by ear needles include the following:

1. Sympathetic (heals physical manifestations of withdrawal)
2. Shen men (calms emotional anxiety)
3. Kidney (and next two are filtering organs of body.)
4. Liver
5. Lung

            The treatments are quite simple.  They simply involve a daily administration of 5 needles in one ear, held in place for 45 minutes per day.  Treatment sessions are non-verbal, i.e. the acupuncturist does not ask for a medical history or any details of drug use, and the patient does not have to volunteer that information.  These treatments are conducted in a group setting.  An herbal tea prepared with a mixture of chamomile, hops, catnip, skullcap, peppermint and yarrow is served, and its purpose is to encourage patients to “feel free to do nothing” and to sleep. A mock demonstration of acupuncture is shown in the following picture, which is of me taken at a conference for prehealth advisors in Portland, OR:

For all this, the initial treatment protocol requires only a daily administration of 5 needles in the ear, held in place for 45 minutes/day.  Urine samples are collected to assess abstinence.

Long-term positive outcomes require additional components:  Group and individual counseling, case management, and education.

B. How acupuncture is applied to the treatment of substance use disorders

The efficacy of acupuncture can be measured if it can reduce any of the following:

• Pain
• Craving
• Anxiety
• Relapse

According to Carol Taub (1988), acupuncture offers a considerable number of benefits:

1. Reduction of craving for the substance;
2. Reduction of withdrawal symptoms;
3. Marked relaxation, a feeling of well-being;
4. Improved sleep patterns;
5. A “clearer mind” which promotes receptive, rational thinking and therefore enhances the benefits of counseling and group experiences;
6. Stimulation and strengthening of particular organ systems, especially the kidney, liver and lungs;
7. Improvement in health problems which often accompany long-term alcohol and drug abuse.

In 1973, the New York Times published an article, Hong Kong Doctors Use Acupuncture to Relieve Addicts’ Withdrawal Symptoms, which described research conducted by a team of physicians at Kwong Wah Hospital showing the efficacy of using electrified acupuncture to treat the withdrawal symptoms of drug addicts.

They admit that the ability to do so was discovered by accident. A 50-year-old male patient was admitted to Kwong Wah Hospital with a brain concussion. Acupuncture anesthesia was used instead of local anesthesia, and during electrostimulation of the acupuncture needles, the patient voluntarily reported complete disappearance of his withdrawal (Wu, et. al., 2016). Of the 40 subsequent cases the team describe in detail, 30 were opium addicts and 10 were heroin addicts. Their ages ranged from 17 to 79, and the duration of their addiction from three to 58 years. The length of treatment varied with the individual and the type and amount of drug taken. In the first few days of treatment, most patients were given two or three stimulations a day of approximately a half‐hour’s duration. This was reduced to a single daily stimulation for the next few days.

After a week to 10 days, most of those treated could be discharged, returning to the hospital as outpatients whenever they felt the need for further treatment.

This discovery has led to more research on the possible applications of acupuncture, particularly of electrical acupuncture in the treatment of opioid withdrawal. Han, et. al., (1991 and 1992) suggest that electrical acupuncture’s mode of antinociceptive action is frequency-dependent, with low frequency (2 Hz) stimulation accelerating production of endorphin and encephalin, and high-frequency stimulation (100 Hz) up-regulates dynorphin level. The increase in dynorphin levels suppresses craving while the increase in endorphin levels suppresses withdrawal symptoms.

Psychological symptoms, such as depression and anxiety, sleep disturbance, and craving are all risk factors for relapse. In randomized tests, patients treated with acupuncture show the following:

• Lower Hamilton Depression Rating Scale
• Reduced anxiety
• Increased rapid eye movement (REM) and non-rapid eye movement (NREM) sleep and total sleep time.

More recently, Kitzman, et. al. (2023) provide several examples and meta-studies which show the benefits of acupuncture, particularly in the treatment of opioid use disorder (OUD):

• Chen, et. al., (2018) describe the efficacy of acupuncture for treatment OUD in 9 studies involving 1,063 participants. Results indicated that acupuncture “reduced withdrawal symptoms, including cravings, insomnia, and depression, compared to no treatment/sham acupuncture;
• Grant, et. al. (2016) found in a review and meta-analysis of 41 studies with 5,227 participants with SUD (Substance Use Disorders), significant differences in favor of acupuncture with regard to craving and anxiety, but not in relapse compared to comparators. However, they noted evidence of publication bias.

II. Guided imagery

A. Before we get to how guided imagery works and how it’s applied to the treatment of SUDs, I think it’s worth looking into how mental images can drive craving, which will lead to relapse. After that, we can look at how guided imagery and other techniques can be used to reduce craving.

^{(Illustration from https://www.narcononarrowhead.org/blog/cravings-as-a-barrier-to-recovery.html)}

There are numerous articles in the scientific literature which assert that craving is a hallmark for relapse. For example:

• Kharb, et. al., (2018) describe a short-term follow-up study of 34 males with alcohol dependence who underwent detoxification and discharge. No anticraving medicine, aversive or psychotherapy, was advised. Severity of Alcohol Dependence Questionnaire (SADQ) and Clinical Institute Withdrawal Assessment Scale–Alcohol-Revised (CIWA-AR) were administered at the time of admission, while the Penn Alcohol Craving Scale (PACS) was applied at the time of discharge and follow-up to measure craving for alcohol. Out of a total of thirty patients analyzed after dropout, 21 relapsed at the end of 1 month. On comparing PACS scores between relapsed and nonrelapsed patients, the difference was significant at both time points, i.e., at discharge and follow-up (t = 4.15, P < 0.0001 and t = 4.01, P < 0.001, respectively). In the total sample, SADQ and CIWA-AR scores were positively correlated (r = 0.47, P = 0.009). PACS at discharge was compared with PACS at follow-up, of which the correlation was high (r = 0.832, P < 0.0001). The research team concluded that “craving seems to be a main factor related to relapse.” Furthermore, the Penn Alcohol Craving Scale (PACS) can be a useful tool to predict subsequent drinking and to identify individual risk for relapse during treatment;
• Stohs, et. al. (2019) use the same Penn Alcohol Craving Scale to measure elevated alcohol craving with post-treatment relapse among 190 190 subjects with DSM-IV diagnosis of alcohol dependence admitted to residential treatment. Follow-up data were available for 149/190 (78%) of subjects. Elevated PACS scores at discharge were associated with increased relapse risk within the first 3 and 12months after discharge, while elevated PACS scores at 3 months were associated with subsequent relapse within 12 months after treatment in contacted subjects;
• Killen and Fortmann (1997) found that craving is also associated with smoking relapse: “In a combined sample of more than 2,600 smokers, immediate postcessation craving is shown to be prospectively associated with smokers’ ability to maintain abstinence. Relapse is strikingly rapid among those reporting high levels of craving following cessation. More than 32% of those with high craving scores relapsed within I week of cessation. In contrast, fewer than 15% of those with low craving scores relapsed in the first week (p < .001). Our findings provide a warrant for an increased research effort designed to provide a better understanding of the factors that control craving following smoking cessation and the processes by which craving influences smoking relapse.”

But what drives craving? In a study of individuals with either alcohol use disorder (AUD) or gambling disorder (GD) but not both, Mansson et. al. (2023) suggest that cravings were initially dominated by imagery, with a subsequent conflict between imagery and verbal thoughts. Craving content included imagery of preparative rituals, anticipation, and sensory activation. Subsequent verbal thoughts resembled self-talk, which often served the purpose of inhibiting addictive impulses through awareness of long-term negative consequences.

If such is the case, then mental imaging can have a powerful influence on motivation and behavior.

B. What it is

According to Christine Carroll (2024), “Guided imagery is a therapeutic technique that utilizes the power of the imagination to influence physical and emotional well-being. This practice involves visualizing specific scenes or activities to promote relaxation, healing, and stress reduction.”

B. How guided imagery is applied to the treatment of substance use disorders

By relaxing the body and controlling some body functions, it is used to treat numerous disorders, including the following:

• Depression
• Anxiety
• Cancer
• Side effects of chemotherapy
• Pain
• High blood pressure
• Obesity
• Diabetes
• Insomnia
• Headaches
• Wounds
• Premenstrual syndrome
• Asthma
• Spastic colon
• Low white blood cell counts

C. Imagery rescripting

According to Arntz (2025), image rescripting “(ImRs) is a transdiagnostic technique by which aversive memories of real (traumatic) experiences, or of aversive fantasies, such as nightmares and future projections can be processed so
that their emotional meaning changes. In short, in ImRs the patient imagines the aversive experience as if it happens in the here and now. At the most difficult moment, called the “hotspot”, the patient imagines that an intervention takes place that changes the course of events in such a way that the patient’s needs are met. This imagination of a new scenario leads to emotional and cognitive processing of the emotional
(trauma) memory, changing the meaning of the experience from dysfunctional to more functional.”

With this approach, an event which was traumatizing can be reinterpreted so that its power to debilitate the patient can be neutralized.

But perhaps it can also be used as a technique to reduce craving.

Imagine the following scenario involving the steps involved in purchasing a bottle of liquor and imbibing, all of which would be perceived as pleasurable:

• 1) You get in your car and drive to a liquor store, no, your favorite liquor store;
• 2) Perhaps you are a steady customer, so a salesperson greets you with a friendly and warm, “Hello, how are you today, Mr./Ms. <Fill-in-the-blank>?” The recognition warms your heart as you head to the display of your favorite liquor. (Mine was vodka);
• You select a bottle, and you start imagining how pleasurable that drink will be once you get home;
• As you drive home, the anticipation of that drink creates a mental picture of you sitting in your easy chair and enjoying your glass. The anticipation alone initiates the release of dopamine in your reward circuitry.

In this imaginary, and perhaps unrealistic, scenario, the mental images which your mind generates are all pleasurable.

Now allow me to share a story involving myself:

About 10 years ago, I was undergoing a very stressful situation involving tending to my older son, who had undergone lower back surgery. His apartment was located close to a liquor store, and every time I walked by, I would start craving a drink. I realized that I was in trouble, so I called my sponsor, who said, “Think the drink through.“

Think the drink through. In other words, visualize the consequences of my actions: 1) The probable resumption of my drinking; 2) The ensuing physical deterioration and demoralization; 3) The complete erasure of the promises as described in the Alcoholics Anonymous “Big Book”.

So my argument here is that thinking the drink through is a form of image rescripting in which your mind generates images of the negative consequences of our behavior, thereby acting as a deterrent.

The evidence for the efficacy of this approach is sparse. Lowry, et. al. (2021) describe a study involving adults with cocaine use disorder (CUD). Although the original target sample was 120, 38 enrolled, with 31 completing the study. Each patient watched a personalized 3 minute video showing the handling of cocaine paraphernalia and drug preparation, immediately followed by a single 5-minute audio-recorded, self-guided and verbally described imagery task with a random assignment to one of four conditions: two mental imagery memory re-experiences (positive image before initiation to cocaine use or a negative image of a ‘worst time’ adverse cocaine use episode, or two future simulations (positive theme of recovery from CUD or negative theme of worsened CUD. Investigators found that in people with cocaine use disorder, after cue-exposure, a self-guided imagery task with positive themes reduced craving, whereas mental imagery simulating worsened cocaine use did not do so.

D. Image-based retrieval-extinction training

Imagery-based retrieval-extinction training (sometimes abbreviated IRT-RE or described as imagery-based retrieval–extinction) is an experimental psychological technique that aims to reduce the emotional impact of distressing or addictive memories by combining two well-established principles:

1. Memory retrieval (reactivation) – briefly bringing a specific memory to mind so that it becomes temporarily “malleable” (a process called reconsolidation).
2. Extinction training – introducing new, non-threatening information while the memory is in that malleable state, with the goal of weakening the learned emotional response.

The “imagery-based” aspect means that, instead of exposing someone to real-life cues, the person uses guided mental imagery to vividly recall the memory or situation.

How it works

A typical session might involve:

1. Guided imagery: The therapist asks the person to vividly imagine a particular event, craving situation, or fear-provoking memory.
2. Brief retrieval: The memory is activated for a short period (often just a few minutes).
3. Timing: There is usually a waiting period (often around 10–60 minutes, depending on the protocol) during which the memory is thought to be undergoing reconsolidation.
4. Extinction: The person is then repeatedly imagines or experiences the same cues without the expected negative or rewarding outcome. For example:
   • Someone with a phobia imagines the feared object without any danger occurring.
   • Someone with alcohol use disorder imagines drinking cues while practicing coping skills and not drinking.

The aim is for the brain to update the memory with new information, so that the cue no longer automatically triggers fear or craving.

Potential uses

Researchers have studied this approach for:

• Anxiety disorders
• Specific phobias
• Post-traumatic stress disorder (PTSD)
• Alcohol and drug use disorders
• Smoking cessation
• Some eating disorders

An example

In 2025, Chen et. al. (2025) describe the application of imagery-based retrieval-extinction in the treatment of nicotine-dependent individuals.

A total of 57 nicotine-dependent individuals were randomly assigned to either the experimental (n=29) or control (n=28) group. Participants were exposed to a 5-minute imagery script cue, followed by a 10-minute rest period and 60-minute extinction training session. Short- and long-term (1 week, 1 month, 3 months, 6 months, 12 months) intervention effects were assessed via the smoking imagery vividness score, smoking craving and daily cigarette consumption.

Regarding short-term effects, smoking imagery vividness score and craving significantly decreased. Regarding long-term effects, the smoking imagery vividness score, smoking craving, and daily cigarette consumption significantly decreased at 1-week and 1-month follow-up. Chen et. al. concluded that this technique demonstrated significant effects on nicotine addiction for 1 month after a single intervention session, suggesting that it is a promising treatment tool.

And, in conclusion regarding guided imagery:

By the way, this is my kind of guided meditation. You have been forewarned. 🤭

III. Yoga

A. What it is

Kuppili, et. al. (2018) describe yoga as a form of mind-body practice which can reduce perceived stress and anxiety, and can improve physical and mental health. Within yoga, there are eight components, including conduct within society, personal discipline, postures/poses (asanas), breathing, concentration, contemplation, meditation, and absorption/stillness.

Since the practice of yoga involves postural control, breath regulation, maintenance of interoceptive awareness, regulation of emotion and attentional control, Singh (2024) suggests that both top-down and bottom up mechanisms of interaction between the brain and peripheral tissues are involved during yoga practice, and with these practices, yoga can bring changes in the psychophysiology of its practitioners:

• Yoga and the brain reward system: Dopamine plays an important role in the reward circuitry as it regulates the reward value of food, drink, sex, social interaction, and substance abuse. In drug addiction, the brain undergoes several changes, including the following: 1) A decrease in dopamine neuronal firing and increased stress; 2) An increase in the expression of D1 receptors, which will reinforce the onset and maintenance of addiction; 3) A decreased expression of D2 receptors, which are found in those regions of the brain associated with executive functions and inhibitory control. One study showed that Rajyoga meditation yields can increase in grey matter volume in reward processing areas of the brain. Increases in endogenous dopamine release have also been reported;
• Yoga and the neurobiology of stress: In the withdrawal/negative affective stage of addiction, stress functions as an important source of motivation for compulsive drug seeking, and contributes to the transition from drug abuse to addiction. In contrast, yoga has been shown to be effective in the reduction of stress, and this is supported by findings from the studies on yoga and heart rate variability. In one study on medical students, after practicing pranayama for 6 months there was a reduction in the low frequency component and an increase in the high frequency of heart rate variability, thereby indicating an increase in parasympathetic activity. In another study, practicing Sudarshan Kriya Yoga for two weeks can lower stress-hormone levels (plasma cortisol and adrenocorticotropic hormone levels) of inpatients of alcohol dependence. It is theorized that the most plausible mechanism for these changes in the autonomic nervous system and stress hormone following the practice of yoga is through the stimulation of the respiratory vagus nerve;
• Yoga and inhibitory control: A compulsive pattern of drug seeking and uncontrolled intake is observed in chronic drug adults. This compulsive behavior is attributed to the dysregulation of the brain’s inhibitory mechanism because of prolonged drug use. Because the practice of yoga requires maintenance of awareness about the object of attention, respiratory sensations and interoceptive feedback from body sensations and mental activity, yoga can improve emotional and cognitive control.

Of all the CAM modalities mentioned at the beginning of this post, yoga in particular has been shown to be an effective alternative therapy, and has been found to reduce stress and addictive behaviors while improving self-esteem and increasing self-control (Walia, et. al., 2021).

The following video is a brief summary of the benefits provided by yoga:

The literature promoting yoga as a modality for drug treatment to 5 different forms, including:

• Hatha yoga
• Pranayama
• Sudarshan Kriya
• Vinyasa yoga
• Kripalu yoga

The following description of these 5 different forms is extracted from an inquiry to ChatGPT:

Hatha yoga: the foundation

Historically, Hatha yoga refers to a broad system of practices that includes physical postures (asana), breath regulation (pranayama), cleansing techniques, concentration, and meditation.

In many Western studios today, “Hatha yoga” usually means a slower-paced class that emphasizes basic postures, longer holds, and foundational breathing techniques.

Pranayama: the breath component

Pranayama is not a style of yoga class but a category of breath-control practices intended to influence physical, mental, and energetic states.

Examples include:

• Alternate nostril breathing (Nadi Shodhana)
• Ocean breath (Ujjayi)
• Bellows breath (Bhastrika)
• Humming bee breath (Bhramari)

Pranayama can be practiced on its own or incorporated into any style of yoga.

Sudarshan Kriya: one specific pranayama method

Sudarshan Kriya is a proprietary, structured sequence of breathing exercises involving slow, medium, and rapid rhythmic breathing patterns.

It is generally taught through certified instructors affiliated with the Art of Living Foundation and is often used as a stress-management and meditation practice.

Vinyasa yoga: movement synchronized with breath

Vinyasa yoga emphasizes continuous movement coordinated with inhalation and exhalation. Classes often vary from teacher to teacher and may include:

• Sun salutations
• Standing poses
• Balancing postures
• Strength and flexibility work

Compared with Hatha and Kripalu classes, Vinyasa tends to be more physically demanding and cardiovascular.

Kripalu yoga: mindfulness and self-study

Kripalu yoga places less emphasis on achieving perfect poses and more emphasis on noticing internal experience.

Typical elements include:

• Gentle movement
• Breath awareness
• Meditation
• Relaxation
• Adaptation to individual needs

Kripalu classes often encourage students to adjust poses according to their comfort, making the approach accessible for beginners, older adults, and people recovering from stress or illness.

Similarities

All five approaches:

• Use conscious breathing as a central tool
• Aim to improve mind-body awareness
• May help reduce stress and improve emotional well-being
• Can include meditation or relaxation elements
• Can be adapted to different levels of experience

I tried to find a video which would compare and contrast these forms of yoga, but couldn’t find any, but perhaps you can get an idea of the different forms of yoga from this:

B. How yoga in its varied forms is applied to the treatment of substance use disorders

Kuppili et. al. (2018) describe a number of studies which indicate the success use of yoga in curtailing the craving for nicotine. For example, in one study conducted by Elibero, et. al, (2011),76 daily smokers participated in a randomized control trial in which they were separated into three groups. One group engaged in a 30-min bout of cardiovascular exercise (CE; brisk walk on a treadmill), a second engaged in Hatha yoga (HY), and the third served as a control and did not engage in any exercise. Participants completed measures of craving and mood, and a smoking cue reactivity assessment, before, immediately following, and approximately 20 min after the physical activity or control conditions. Results indicated that compared with the control group, participants in each of the physical activity groups reported a decrease in craving to smoke, an increase in positive affect, and a decrease in negative affect. In addition, craving in response to smoking cues was specifically reduced among those who engaged in CE, whereas those who engaged in HY reported a general decrease in cravings.

Walia, et. al., (2021) searched five databases for randomized controlled trials (RCTs) that evaluated yoga as an intervention in adults with any type of substance use disorder. The interventions studied included Hatha yoga, Sudarshan Kriya yoga, breathing yoga exercises, and meditation. Among the 8 final studies eligible for analysis, they found the following:

• Two had undefined substance use, while the others were focused on tobacco, alcohol or opioids;
• Seven of 8 studies showed significant results and improved primary outcomes such as anxiety, pain, or substance use;
• Seven out of the 8 studies showed significant positive outcomes using yoga in conjunction with other pharmacological treatment modalities such as opioid substitution therapy.

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