Psychological and Physical Approaches for Substance Use Disorders: What the Science Says

Hypnotherapy

There is some evidence to suggest that hypnotherapy may improve smoking cessation, but data are not definitive. There is some evidence that hypnotherapy, compared to an active education control, can reduce the risk of daily cannabis use.

What Does the Research Show?

• A 2023 randomized controlled trial of 378 veterans examined the impact of three behavioral interventions for chronic pain on substance use—hypnotherapy, mindfulness meditation, and an active education control. The study found that hypnotherapy for chronic pain, as compared to the education control, significantly reduced risk of daily cannabis use by 82 percent at the 6-month posttreatment follow-up after adjusting for baseline use. There was no effect on tobacco or alcohol use at posttreatment follow-ups.
• A 2014 randomized controlled trial of 164 patients hospitalized with cardiac or pulmonary illness compared the efficacy of hypnotherapy alone for smoking cessation, as well as hypnotherapy with nicotine replacement therapy, to conventional nicotine replacement therapy alone. The study found that hypnotherapy patients were more likely than nicotine replacement therapy patients to be nonsmokers at 12 weeks and 26 weeks after hospitalization.
• A 2019 Cochrane review of 14 studies compared hypnotherapy with 22 different control interventions. The authors found that there is insufficient evidence to determine whether hypnotherapy is more effective for smoking cessation than other forms of behavioral support or unassisted quitting. The noted that if a benefit is present, current evidence suggests the benefit is small at most.

Safety

• Hypnosis is considered safe when performed by a health professional trained in hypnotherapy.

Mindfulness Meditation

Available data suggest that mindfulness-based interventions may help significantly reduce the consumption of several substances including alcohol, cigarettes, opiates, and others compared to control groups; however, many studies have had small sample sizes, methodological problems, and a lack of consistently replicated findings. There is some evidence that mindfulness meditation, compared to an active education control, can reduce the risk of daily cannabis use. There is evidence that adding the mindfulness-oriented recovery enhancement (MORE) program to standard methadone treatment leads to therapeutic benefits in people with opioid use disorder and chronic pain.

What Does the Research Show?

• A 2024 randomized controlled trial of 54 racially diverse opioid users with chronic pain found that adding 8 weeks of the mindfulness-oriented recovery enhancement (MORE) program to standard methadone treatment resulted in lower risks of returning to drug use and treatment dropout as well as fewer days of any drug use at 16 weeks. Standard methadone treatment included daily medication and individual or group counseling (without mindfulness) that was usually done remotely through telehealth. The MORE program included eight weekly 2-hour group therapy sessions over videoconferencing plus weekly homework practice. At 16 weeks, 83.6 percent of those in standard methadone treatment continued to take methadone, whereas the treatment adherence increased to 95.5 percent in participants receiving MORE plus standard treatment. The MORE participants also had greater reductions in depression and pain at 16 weeks when compared to the standard treatment participants.
• A 2023 randomized controlled trial of 378 veterans examined the impact of three behavioral interventions for chronic pain on substance use—hypnotherapy, mindfulness meditation, and an active education control. The study found that mindfulness mediation, as compared to the education control, significantly reduced risk of daily cannabis use by 85 percent and 81 percent at the 3- and 6-month posttreatment follow-ups, respectively, after adjusting for baseline use. There was no effect on tobacco or alcohol use at posttreatment follow-ups.
• A 2016 review found that mindfulness-based interventions effectively reduce pain intensity, improve functional status, improve pain-related psychological consequences, and improve quality of life; they can also be used as adjunct therapy aimed at improving health-related quality of life in individuals with substance use disorders interested in self-management strategies. (Strength of Recommendation: B) Further, in smokers, mindfulness training used as adjunct therapy with pharmacotherapy shows efficacy in maintaining abstinence comparable to standard of care. (Strength of Recommendation: B)
• A 2014 systematic review of 24 studies found evidence suggesting that mindfulness-based interventions can reduce the consumption of several substances including alcohol, cocaine, amphetamines, marijuana, cigarettes, and opiates to a significantly greater extent than waitlist controls, nonspecific educational support groups, and some specific control groups. The review also found preliminary evidence suggesting that mindfulness-based interventions are associated with a reduction in cravings. However, the findings are limited due to small sample sizes of the studies and lack of methodological details.
• Relapse is common following substance abuse treatments. In a 2014 randomized controlled trial involving 286 individuals who successfully completed initial treatment for substance use disorders, mindfulness-based relapse prevention (MBRP; a group-based psychosocial aftercare that integrates evidence-based practices from mindfulness-based interventions and cognitive behavioral relapse prevention (RP) approaches) was compared to cognitive behavioral RP alone and to 12-step programming and psychoeducation (treatment as usual (TAU)). Compared with TAU, participants assigned to MBRP and RP reported significantly fewer days of substance use and heavy drinking at the 6-month follow-up. Cognitive behavioral RP showed an advantage over MBRP in time to first drug use. MBRP participants, however, reported significantly fewer days of substance use and significantly decreased heavy drinking at the 12-month follow-up, compared with RP and TAU. These results suggest that mindfulness practices may help reduce the risk of substance abuse relapse by strengthening the ability to monitor and cope with discomfort associated with drug craving or negative affect.
• Several studies in smokers have used functional magnetic resonance imaging to examine the effects of mindful attention on the anterior cingulate and prefrontal cortex, the areas of the brain associated with cravings and self-control. In a 2017 study of 23 participants who completed either mindfulness training or cognitive behavioral treatment for smoking cessation, the researchers found that stress reactivity in several brain regions including the amygdala and anterior/mid insula was related to reductions in smoking after treatment. These same regions also differentiated between treatment groups such that the mindfulness training group showed lower stress-reactivity compared to the cognitive behavioral treatment group. The findings suggest that reduction in stress reactivity may be one of the underlying mechanisms of mindfulness-based treatments. In a 2013 study, participants’ self-reported results demonstrated that mindful attention reduced cravings. In addition, the brain imaging results indicated that mindful attention reduced neural activity in a craving-related region of the subgenual anterior cingulate cortex. In another 2013 study, a 2-week course of meditation (5 hours in total) produced a significant reduction in smoking, compared to a relaxation training control. Results of brain imaging showed increased activity for the meditation group in the anterior cingulate and prefrontal cortex.

Safety

• Meditation is considered to be safe for healthy people.
• There have been rare reports that meditation could cause or worsen symptoms in people who have certain psychiatric problems, but this question has not been fully researched.

Music-Based Interventions

There is evidence that music therapy as adjunct treatment to standard care can lead to moderate reductions in substance craving and can increase motivation for treatment/change for people with substance use disorders receiving treatment in detoxification and short-term rehabilitation settings. Music therapy may also have an effect on emotional and motivational outcomes and perceived helpfulness for substance use disorders.

What Does the Research Show?

• A 2022 Cochrane systematic review of 21 trials involving a total of 1,984 participants concluded that music therapy as adjunct treatment to standard care can lead to moderate reductions in substance craving and can increase motivation for treatment/change for people with substance use disorders receiving treatment in detoxification and short-term rehabilitation settings. Greater reduction in craving is associated with music therapy lasting longer than a single session.
• A 2017 systematic review of 34 quantitative and 6 qualitative studies found beneficial effects of music therapy and music-based interventions on emotional and motivational outcomes, participation, locus of control, and perceived helpfulness, but results were inconsistent across studies. The authors concluded that the efficacy of the interventions remains unclear.

Yoga

Only a few studies have been conducted on the effects of yoga for substance abuse disorders. Although preliminary results have been positive, larger, high-quality studies are needed to determine rigorously if yoga is an effective treatment.

What Does the Research Show?

• A 2021 systematic review of eight studies evaluated yoga as an intervention in adults with any type of substance use disorder. Seven out of the eight studies included in the review found significant results and improved primary outcomes measuring anxiety, pain, or substance use. In addition, seven out of the eight studies showed significant positive outcomes using yoga in conjunction with other pharmacologic treatment modalities such as opioid substitution therapy. However, the reviewers noted that randomized controlled trials with larger sample size are needed to better evaluate the effectiveness of yoga as a treatment modality for substance use. Furthermore, additional studies are needed that compare the effect of yoga on specific substances of abuse to determine the efficacy of using yoga as a main-line treatment for different types of substance misuse.
• A 2019 study of 227 adult smokers found that yoga participants had 37 percent greater odds of achieving abstinence than the control group at the end of treatment. Participants with lower baseline smoking rates (≤10 cigarettes/day) also had a higher likelihood of quitting if in the yoga group versus the control group.

Safety

• Yoga is generally low-impact and safe for healthy people when practiced appropriately under the guidance of a well-trained instructor.
• Overall, those who practice yoga have a low rate of side effects, and the risk of serious injury from yoga is quite low. However, certain types of stroke as well as pain from nerve damage are among the rare possible side effects of practicing yoga.
• Women who are pregnant and people with certain medical conditions, such as high blood pressure, glaucoma, and sciatica, should modify or avoid some yoga poses.

References