DEALING WITH OPIOID AND HEROIN EPIDEMIC NONMEDICATION

DEALING WITH OPIOID AND HEROIN EPIDEMIC & NONMEDICATION TREATING OF PAIN Jim Messina, Ph. D. , CCMHC, NCC, DCMHS-T Lecturer: Troy University, Tampa Bay Site This Power. Point and more information on topic at: http: //www. coping. us/opioidheroinepidemic. html

About this Course This program takes an intervention orientation to the Opioid and Heroin Epidemic with a view towards understanding the full range of Medication Assisted Treatments (MAT) for the Opioid and Heroin Addiction. There also needs to be a holistic approach to treating people with this condition. These holistic approaches can be used as alternatives to the use of medication in treating chronic or acute physical pain which has up to this point in time been the gateway to this epidemic. This epidemic has gotten the public's attention and it is imperative that mental health professionals, no matter in what setting they work, are informed and up to date about the epidemic, its treatment and its prevention. Finally, It is important that Mental Health Professionals become skilled In many of the holistic approaches which are promoted in the treating of this epidemic as well as in the treating of chronic and acute pain.

Learning Objectives 1. To learn about the impact of the Opioid and Heroin Epidemic in America today with an exploration of what are the underlying issues which are feeding this epidemic’s breadth and depth in America. 2 To learn about the neuroscience involved in the use of opioid and heroin to satisfy the mesolimbic region of the brain and to learn what can be done to turn this addicting process around through the use of both medication assisted treatment and Cognitive Behavioral Therapy approaches 3. To learn about Holistic Therapeutic Techniques which clients can use to recover from their addictions as well as deal with their chronic pain in a non-medicating way so they can grow stronger and committed to personal growth and recovery despite what the challenges are that come their way. 4. To learn about the Holistic Approaches to supplement the treatment of coping with opioids, heroin and chronic pain such as: Mindfulness, Biofeedback, Creative Arts, Equine Assisted Therapy, Gardening, Guided Imagery, Hypnosis, Journaling, Massage and Body Work.

BACKGROUND ON OPIOID AND HEROIN EPIDEMIC

Update on the Opioid Crisis On July 31, 2017, The President's Commission on Combating Drug Addiction and Opioid Crisis put out its first interim report asking the President and the Cabinet to declare a state of emergency to quickly and aggressively address this crisis - see article on Medscape at: http: //www. medscape. com/viewarticle/883627 Some 142 Americans die every day from a drug overdose, said Christie, chairman of the President's Commission on Combating Drug Addiction and the Opioid Crisis, in a press briefing. The declaration of a national emergency is "the single-most important recommendation, " Christie said.

Opioid-Heroin Epidemic Defined CDC's official definition of an epidemic is: "The occurrence of more cases of disease than expected in a given area or among a specific group of people over a particular period of time. ” ■ Since 1999 the rate of overdose deaths involving opioids including both prescription pain medication and heroin nearly quadrupled ■ Heroin use has increased across the US among men and women, most age groups, and all income levels Factors Driving the Epidemic ■ Wider availability of prescription opioids ■ 1999 -2013 the amount of prescription opioids dispensed in the US nearly quadrupled ■ Increasing non-medical use and overdose ■ Changing economics and supply of heroin ■ Cheaper, available, higher purity, synthetics ■ Increasing heroin use and overdose ■ Lack of access to treatment ■ 80% with SUD are not in treatment

Prevalence of Pain and Substance Use Disorders (SUD) ■ 100 million Americans have persistent pain- IOM study, 2011 ■ Pain costs society at least $560‐$635 billion annually IOM study, 2011 ■ $261‐$300 billion in health care costs ■ $297‐$336 billion in lost productivity ■ In 2013, 1. 9 million people had a substance use disorder SAMHSA, 2014

Prescribed Opioid Abuse ■ Over 16, 000 died of an opioid‐related overdose SAMHSA, 2014 ■ 4. 3 million nonmedical users of Prescribed opioids age 12 or older - SAMHSA, 2014 ■ 467, 000 adolescents were current nonmedical users of prescribed opioids, with 168, 000 having an addiction to them - SAMHSA, 2014

Abuse of Other Controlled Prescribed Medications A. Stimulants ■ 17% of college students abuse prescribe ADHD medications ■ 20% of middle and high school students with prescribed medications are asked by friends for medications; 50% give medications to friends B. Benzodiazepines ■ Overdose deaths quadrupled between 2001 and 2013 ■ PA: Present in 50% of drug‐related overdose deaths - 40% involved alprazolam ■ GA: Misuse of alprazolam leading cause of drug‐related death -35%, 231 out of 644 C. Sedatives ■ Violence ■ “Ambien defense” to murder ■ Zolpidem sleep medication is most common date rape drug - DEA ■ Impaired driving “sleep‐driving”

Epidemic by the numbers On an average day: ■ 650, 000 opioid prescriptions dispensed ■ 3, 900 people initiate nonmedical use of prescription opioids ■ 580 people initiate heroin use ■ 91 people die from an opioid related overdose

Opioid Deaths in the USA in 2015

Heroin Deaths in the USA in 2015

Re-emergence of Fentanyl ■ Schedule II synthetic opioid analgesic ■ Up to 50 -100 x more potent than morphine and 30 -50 x than heroin ■ Mixed with adulterants and sold as “synthetic heroin” ■ 2015 death rate from synthetic opioids increased 72. 2% ■ Comes from several sources ■ Diverted from legal medical use ■ Clandestine – manufactured in Mexico or China

Synthetic Opioid Deaths in 2015

Natural Opioid Deaths in the USA

Risk Groups for Prescription Opioid Misuse ■ ■ Men ages 25 -54 White and American Indian/Alaska Natives People in rural areas, especially in the Appalachian region People who obtain multiple controlled substance prescriptions from multiple providers ■ Teens and young adults (One in four teens has misused or abused a prescription drug at least once in their lifetime) ■ People who take high daily dosages of opioid pain relievers (veterans with injuries, those with occupational injuries) ■ Increasingly women and older adults over 65

Risk groups for Heroin Addiction ■ People who are addicted to prescription opioid painkillers are at most risk for addiction to heroin ■ People who are addicted to cocaine ■ People without insurance or enrolled in Medicaid ■ Non-Hispanic whites ■ Males ■ People living in large metropolitan areas, particularly in the Northeast and Midwest

The relationship between Heroin & Prescription Opioids ■ Both prescription opioids and heroin are chemically related and just as addictive ■ Act on nerve cells in the brain and nervous system the same way – pleasurable effects and relieve pain ■ People who are addicted to prescription opioid painkillers are at high risk for addiction to heroin 19 x more likely to use ■ Injecting drug use (IDU) increases the risk of serious, long-term viral infections such as HIV, Hepatitis B and C ■ 11% of new HIV infections are from Injecting Drug Use (IDU) ■ 50% of new Hepatitis C infections are from Injecting Drug Use (IDU) ■ 114% increase in Emergency Room and Doctor visits ■ Neo-natal abstinence syndrome ■ Increase in fractures in older adults due to falls ■ Significant co-occurring Myocardial Infarction (health attacks) with SUD ■ Anxiety, mood disorders, depression

Heroin Use ■ 517, 000 had a heroin use disorder, compared with 189, 000 in 2002 -SAMHSA, 2014 ■ Between 2002 and 2013, the rate of heroin‐related overdose deaths nearly quadrupled. Over 8, 200 died in 2013 - CDC ■ People who abuse prescribed opioids rarely use heroin, and the transition to heroin use appears to occur at a low rate - NIDA 2016 Researchers suggest that the major drivers of the recent heroin use increases and related deaths are: ■ Increased accessibility ■ Lower market price ■ High purity

Heroin Supply A. Heroin Pills ■ Counterfeit oxycodone containing heroin in KY & OH ■ Indistinguishable from legitimate pills; identified through lab tests B. Heroin laced with fentanyl ■ 40 times as strong as pure heroin ■ 700 heroin-fentanyl‐related deaths from late 2013 through 2014 ■ 74 people overdosed in 3 days in Chicago C. “China White” – heroin laced with acetyl fentanyl-analog ■ Deaths jumped 500% -43 in ME between 2013 and 2014 ■ 600% increase in deaths -49 in Cabarrus County, NC D. Hollywood – “exceptionally” lethal form of heroin ■ 8 people overdosed in 1 week in Western Massachusetts

The Hepatitis C/HIV Infection Epidemic ■ 150% increase in new infections 2010 -2013 ■ Almost 50% of new cases associated with injection drug use ■ Occurring in young people (<30), in rural and suburban areas ■ Use of oral prescription opioids before transitioning to injecting Hepatitis C and HIV transmissions Outbreak in southeastern Indiana community of 4, 200: 170 with HIV and 122 with hepatitis C- 06/2015 Miami‐Dade and Broward County are the top two counties in the U. S. for new HIV cases; transmissions presumed to be associated w/ opioid abuse/heroin use-09/2015

Partial Progress Decrease in prescription drug abuse‐related deaths ■ CDC: 3% nationwide in 2012 ■ SAMHSA: 14% among adults ages 18 to 25 nationwide in 2011 Decrease in prescription opioid‐related deaths ■ CDC: 5% nationwide in 2012 - 1 st time in over a decade ■ 27% in FL between 2010 and 2012 ■ 29% in Staten Island between 2011 to 2013

Making this Epidemic More Personal – What’s Happening in Our Own Back Yard? On the morning of February 25, 2017 as the website for this program was being uploaded the following article appeared in the Tampa Bay Times: “From the shadow of pill mills, a new drug crisis emerges in Tampa Bay. ” It was written by John Romano a Times Columnist. Here is a summary of what he had to say: We are six years past the peak of the pill mill epidemic, and Pinellas County is going through another killer drug crisis. Eliminating pill mills and doctor shopping was a necessary first step. But Florida, and many other states, never fully invested in the second step, which should have been providing better rehab and follow-up for opioid addicts caught in the court system. The statistics are still preliminary but the number of fatal overdoses in Pinellas jumped at least 53 percent from 2015 to 2016. There were 274 confirmed overdoses and, with seven cases still pending, the final tally could eclipse the 280 deaths in 2010 when oxycodone abuse was rampant. Pasco County had a 34 percent increase in drug deaths in 2016. Hillsborough County has not yet tallied its numbers, but expects an increase. This time around, it is being driven by a combination of heroin and fentanyl. The potency is higher and the cost cheaper, and so the results are tragically familiar.

Making this Epidemic More Personal – What’s Happening in Our Own Back Yard? Part 2 The Florida Department of Law Enforcement reported heroin deaths in Florida were up about 75 percent, and fentanyl deaths were up 70 percent from 2014 to 2015. Higher totals are expected when the state's 2016 reports are released later this year. A county commissioner from Palm Beach and a state senator from Miami-Dade have recently called on Gov. Rick Scott to declare a public health emergency, as he did in 2011 for the oxycodone crisis. "In Florida, it's an epidemic. Nationally, this is a pandemic, '' said Jim Hall, the co-director for the Center for Applied Research on Substance Abuse at Nova Southeastern University. "We've gone beyond a crisis level to an emergency level. ‘’ Fentanyl is a painkiller, along the lines of morphine, often used to treat cancer patients. Produced mostly in Asia and apparently funneled through Mexico, it is far more powerful than heroin. Variations of fentanyl, including carfentanil, which is an animal tranquilizer that can be 100 times more potent than heroin, can be deadly with just a few drops. "It's a lot cheaper than heroin, especially the analogs, '' said Bill Pellan, director of investigations for the Pinellas-Pasco Medical Examiner's Office. "They can take a tiny bit, and cut it with whatever, and now they have a lot more bags to sell. The same quantity of heroin might get you 10 baggies, versus 100 baggies with fentanyl. It's cheap and it's available, so there's a demand for it. ''

Making this Epidemic More Personal – What’s Happening in Our Own Back Yard? Part 3 At one point, it was difficult to know if users realized they were getting heroin laced with fentanyl. There was an outbreak early last year in Tampa Bay with fentanyl being pressed into Xanax pills that led to a handful of deaths for the unsuspecting. Now, however, investigators say some users have told them they look for fentanyl. Bill Pellan said labs are seeing examples of confiscated supplies in syringes or baggies that contain fentanyl but no heroin. What should we do? ■ We need to work in a united collaborating way to intervene early in the lives of youth to address those issues which drive them to experiment. ■ We need to engage with users in better wrap around services which support them in their efforts to free themselves from this addiction. ■ We need to get the whole community to be supportive of the efforts to work on ridding our local communities from this scourge.

Strategies for Addressing this Epidemic A. Evidence Based Some evidence-based interventions exist to inform action to address this public health emergency; these should be scaled up and widely disseminated. Furthermore, many promising ideas are evidence-informed, but have not yet been rigorously evaluated. The urgent need for action requires that we rapidly implement and carefully evaluate these promising policies and programs. The search for new, innovative solutions also needs to be supported by research and/or promising practices and understanding that SUD’s are a brain disease that can be treated. B. Cross System The desired goal is developing approaches that intervene all along the supply chain, and in the clinic, community and addiction treatment settings. Interventions aimed at stopping individuals from progressing down a pathway that will lead to misuse, abuse, addiction and overdose are needed. Effective primary, secondary and tertiary prevention strategies are vital. The importance of creating synergies across different interventions to maximize available resources is also critical. Legal, health, government, private/public, education, research/science, law enforcement, first responders, all personal need to be engaged.

Strategies for Addressing this Epidemic Part 2 C. Comprehensive Used appropriately, prescription opioids can provide relief to patients. However, these therapies are often being prescribed in quantities and for conditions that are excessive, and in many cases, beyond the evidence base. Such practices, and the lack of attention to safe use, storage and disposal of these drugs, contribute to the misuse, abuse, addiction and overdose increases that have occurred over the past decade. What is needed are efforts to maximize the favorable risk/benefit balance of prescription opioids by optimizing their use in circumstances supported by best clinical practice guidelines. ■ Address the combined and interrelated epidemics ■ Prevention, intervention, and treatment ■ Alternative way to assist in pain management

Evidence Informed Public Policy Maximize use of Prescription Drug Monitoring Programs (PDMP’s) Using Prescription Drug Monitoring Program Data to Support Prevention Planning Payment policies that expand access/linkage to treatment/medications Prescriber education requirement ■ Opioid prescribing guidelines: Preventing Prescription Drug Misuse: Overview of Factors and Strategies ■ Review data and practices of Medicaid, workers comp programs, benefit managers ■ Syringe services programs: HIV and Injection Drug Use Syringe Services Programs for HIV Prevention ■ Good Samaritan laws ■ Increase access to and training on use of Naloxone (Narcan) ■ Physical exam requirement prior to prescription ■ ID requirement prior to dispensing controlled substances Laws to eliminate pill mills (State of Florida Legislature Initiative) PSA’s Governor led task forces: National Governors' Association's Finding Solutions to the Prescription Opioid and Heroin Crisis: A Road Map for States

Everyone has a role in addressing this epidemic ■ ■ ■ ■ ■ Addiction/Behavioral Health treatment providers Healthcare providers/professionals Hospitals Law enforcement/lawmakers Peers/peer support organizations Educators/colleges/universities/schools Faith leaders Families Drug prevention coalitions

Public Health Approach to Dealing with this Epidemic “By adopting an evidence-based public health approach, America has the opportunity to take genuinely effective steps to prevent and treat substance-related issues”. ■ ■ Prevent initiation Prevent escalation from use to disorder Shorten the duration of illness Reduce the number of substance related deaths HHS Office of the Surgeon General (2016). Facing Addiction in America: The Surgeon General’s Report on Alcohol, Drugs, and Health

The Public Health Approach We are all part of the solution!! 1. Prevention 2. Early Intervention 3. Treatment 4. Recovery

1. Prevention ■ Educating the public on the risk of prescription opioid use ■ Tolerance, addiction, overdose, death ■ Educating healthcare providers on safe prescribing/treatment of pain ■ Guidelines such as the: Opioid Overdose Prevention TOOLKIT ■ Non-opioid chronic pain management such as: Managing Chronic Pain in Adults With or in Recovery From Substance Use Disorders ■ Reduce stigma associated with addiction ■ Language ■ Use of medications to treat addiction (MAT) ■ Treatment of chronic illness

2. Early Intervention ■ Screening/Identification - All ages, multiple settings: www. integration. samhsa. gov/clinical-practice/screeningtools#drugs ■ Brief interventions - Short conversation to provide feedback and advice ■ Referral to treatment with a warm handoff ■ Overdose prevention, use of naloxone (narcan): Opioid Overdose Prevention TOOLKIT ■ Syringe service programs using guidelines such as: HIV and Injection Drug Use Syringe Services Programs for HIV Prevention

3. Treatment Long term ■ Detox is a first step Medications ■ Methadone ■ Buprenorphine ■ Naltrexone Psychosocial Interventions ■ CBT (relapse prevention, 12 step facilitation, social skills) ■ Individual, group, family counseling Recovery Supports ■ Peers

4. Recovery An Integrated Approach ■ Focusing on the Whole Person ■ Integrating behavioral health into the HIV care continuum ■ Integrating behavioral health into the primary care system ■ Integrating behavioral health into the education/school systems Community Partnerships - Goal: Every door is the right door ■ SUD Treatment Programs and Emergency Rooms ■ Public health and behavioral health programs ■ Primary care and SUD treatment programs ■ Schools and prevention coalitions ■ Entitlement programs (Medicaid) and SUD treatment programs ■ HHS training and Technical Assistance center collaborative

What the People Involved with this Epidemic can do

1. The people who are over-using prescription pain killers (opioids) can do Talk with their doctors about: ■ The risks of prescription painkillers and other holistic ways to manage their pain ■ Making a plan on when and how to stop, if a choice is made to use prescription painkillers ■ Use prescription opioids only as instructed by their doctors ■ Store prescription painkillers in a safe place and out of reach of others ■ Never use another person's prescription opioids

2. The Prescribers Talk with their patients about the risks of taking prescription opioids, including addiction/tolerance, overdose and death ■ Prescribe the lowest effective dose, only the quantity needed for the expected duration of pain and/or discuss other options to manage pain ■ Follow best practices for responsible opioid prescribing ■ CDC guidelines for chronic pain ■ American Society for Addictive Medications (ASAM) guidelines ■ Use their state’s Prescription Drug Monitoring Program (PDMP) to identify patients who might be misusing prescription drugs and are at risk of overdose ■ Become trained to provide medications for addiction

3. Healthcare/Treatment Providers ■ ■ ■ Treat the whole person – integrated approach Address health beliefs, wellness, health literacy Regularly screen for depression and use of substances Talk with their patients about the risks of using opioids Identify and reach out to potential partners in their communities, provide information on their services

4. All of Us ■ Learn more about the risks of using heroin and other drugs ■ Learn how to recognize and respond to an opioid overdose (SAMHSA Overdose Tool Kit) ■ Know how to access treatment resources in your community (State Website: www. statename. gov) ■ Behavioral Health Agency, Mental Health/Substance Abuse Treatment Agencies, ■ Be aware of what policies and practices that the State is implementing ■ Stay updated!

Resources A Call for Differential Diagnosis of Non‐Specific Low Back Pain to Reduce Opioid Abuse, 101 Journal. Of Medicine. REG. 39 2015. Abuse‐Deterrent Formulations: Transitioning the Pharmaceutical Market to Improve Public Health and Safety, Therapeutic Advance in Drug Safety, 67, 2015. Active Verification and Vigilance: A Method To Avoid Civil and Criminal Liability When Prescribing Controlled Substances, Depaul Journal of Health Care, 93, 2013. The Best of Both Worlds: Applying Federal Commerce and State Police Powers To Reduce Prescription Drug Abuse. Journal of Health Care & Policy 271, 2013

GUIDELINES FOR PRESCRIPTION OF OPIOIDS

What is Chronic Pain? Chronic Pain Syndrome (ICD-10 CM G 89. 4) ■ Pain for at least 3 months AND: ■ Extreme focus on and/or amplification of pain ■ Major inactivity and/or deconditioning ■ Disrupted sleep ■ Multiple work ups and/or failed treatments ■ Depression and irritability ■ Significant reduction in social activities

Prevalence of Chronic Pain ■ 50 million American adults with chronic pain ■ 25 million had daily chronic pain ■ 23 million more reported severe pain (affecting their activities of daily living- ADLs) Pain Conditions ■ Low back pain 35% ■ Migraine 7. 5% ■ Fibromyalgia 7% ■ Lumbar radiculopathy 4. 5% ■ Cervical radiculopathy 3. 5% ■ Neuropathy 5% ■ Other neurologic condition 5%

More on Pain Biopsychosocial Model of Pain ■ Pain is a subjective experience ■ It is a physical sensation, but it is an unpleasant and therefore emotional experience ■ Pain impacts and is impacted by various factors ■ Necessary to address all to impact the development, maintenance, and impact of chronic pain Psychological Factors and Pain ■ A mild degree of depression, anxiety, and irritability is abnormal psychological response to pain ■ 30 -40% of those with chronic pain in Primary Care fall into the subgroup with significant psychiatric comorbidity ■ 50 -75% in pain specialty settings with major depression or anxiety disorder

Opioids Prescribed in the USA ■ Avinza - morphine sulfate ER capsules ■ Kadian - morphine sulfate ER capsules ■ Butrans - buprenorphine transdermal system ■ Methadose - methadone hydrochloride tablets ■ Dolophine - methadone hydrochloride tablets ■ Duragesic - fentanyl transdermal system ■ Embeda - morphine sulfate/naltrexone ER capsules ■ Exalgo - hydromorphone hydrochloride ER tablets ■ Hysingla - ER (hydrocodone bitartrate) ER tablets ■ MS Contin - morphine sulfate CR tablets ■ Nucynta - ER tapentadol ER tablets ■ Opana - ER oxymorphone hydrochloride ER tablets ■ Oxy. Contin - oxycodone hydrochloride CR tablets ■ Targiniq - oxycodone hydrochloride/naloxone hydrochloride ER tablets ■ Zohydro - hydrocodone bitartrate ER capsules

Opioids Prescribed in the USA Generic Products ■ Fentanyl ER transdermal systems ■ Methadone hydrochloride tablets ■ Methadone hydrochloride oral concentrate ■ Methadone hydrochloride oral solution ■ Morphine sulfate ER tablets ■ Morphine sulfate ER capsules ■ Oxycodone hydrochloride ER tablets

First: Conduct thorough Heath & Physical Exam and appropriate testing Benefits include: ■ Analgesia (adequate pain control) ■ Improved Function Risks Include: ■ Overdose ■ Life Threatening respiratory depression ■ Addiction ■ Physical dependence including tolerance ■ Interactions with other medications & Substances ■ Risk of neonatal withdrawal syndrome with prolonged use during pregnancy ■ Misuse by patient or household contacts ■ Inadvertent exposure/ingestion by household contacts, especially children Importance of Documentation ■ Adequately document all patient interactions, assessments, test results, & treatment plans

Clinical Interview: Patient Medical History Illness relevant to (1) effects or (2) metabolism of opioids 1. Pulmonary disease, constipation, nausea, cognitive impairment 2. Hepatic, renal disease Illness possibly linked to addiction, e. g. : ■ Hepatitis ■ HIV ■ Tuberculosis ■ Cellulitis ■ Sexually Transmitted Infections (STI’s) ■ Trauma, Burns ■ Cardiac Disease ■ Pulmonary Disease

Clinical Interview: Pain & Treatment History Description of Pain ■ Location ■ Intensity ■ Quality ■ Onset/Duration ■ Variations/Patterns/Rhythms ■ What relieves pain? ■ What causes or increases pain? ■ Effects of pain on physical, emotional, and psychosocial function ■ Patient’s pain and functional goals

Pain Medications ■ Past Use ■ Current Use ■ Query Prescription Drug Monitoring Programs (PDMPs) where available to confirm patient report ■ Contact past providers & obtain prior medical records ■ Conduct Urine Drug Testing (UDT) ■ Dosage ■ General effectiveness ■ Nonpharmacologic strategies & effectiveness

Perform Thorough Evaluation & Assessment of Pain ■ Seek objective confirmatory data ■ Components of patient evaluation for pain ■ Order diagnostic tests (appropriate to complaint) General: vital signs, appearance, posture, gait, & pain behaviors ■ Neurologic exam ■ Musculoskeletal Exam ■ Inspection ■ Palpation ■ Percussion ■ Auscultation ■ Provocative maneuvers ■ Cutaneous or trophic findings

Assess Risk of Misuse and Addiction, Including Substance Use & Psychiatric History Obtain a complete History of current & past substance use ■ Prescription medications ■ Illegal substances ■ Alcohol & Tobacco (Substance misuse/addiction history does not prohibit treatment with ER/LA opioids but may require additional monitoring and expert consultation and referral) ■ Family history of substance abuse & psychiatric disorders ■ History of trauma, especially physical or sexual abuse

Be knowledgeable about risk factors for opioid use disorder ■ Personal or family history of substance use disorder ■ Younger age ■ Presence of psychiatric condition Understand use screening tools ■ Assess potential risks associated with chronic opioid therapy ■ Manage patients using ER/LA opioids base on risk assessment ■ Conduct a Urine Drug Testing (UDT) ■ Understand its limitations

The DOs and DON’Ts of Extended-Release/ Long-Acting Opioid Analgesics DO: ■ Read the Medication Guide ■ Take your medicine exactly as prescribed ■ Store your medicine away from children and in a safe place ■ Flush unused medicine down the toilet ■ Call your healthcare provider for medical advice about side effects. ■ You may report side effects to FDA at 1 -800 -FDA-1088. Call 911 or your local emergency service right away if: ■ You take too much medicine ■ You have trouble breathing, or shortness of breath ■ A child has taken this medicine

Talk to your healthcare provider: ■ If the dose you are taking does not control your pain ■ About any side affects you may be having ■ About all the medicines you take, including over-the- counter medicines, vitamins, and dietary supplements DON’T: ■ Do not give your medicine to others ■ Do not take medicine unless it was prescribed for you ■ Do not stop taking your medicine without talking to your healthcare provider ■ Do not cut, break, chew, crush, dissolve, snort, or inject your medicine. If you cannot swallow your medicine whole, talk to your healthcare provider. ■ Do not drink alcohol while taking this medicine ■ For additional information on your medicine go to: dailymed. nlm. nih. gov

Keep Specific Information on Extended-Release / Long-Acting Opioid Analgesics You have been Prescribed ______________________________ ______________________________ Take this information with you every time you see your healthcare provider and tell him/her: ■ Your complete medical and family history, including any history of substance abuse or mental illness ■ If you are pregnant or are planning to become pregnant ■ The cause, severity, and nature of your pain ■ Your treatment goals ■ All the medicines you take, including over-the- counter (non-prescription) medicines, vitamins, and dietary supplements ■ Any side affects you may be having Take your opioid pain medicine exactly as prescribed by your healthcare provider.

Benefit of the Tools for Monitoring the Prescription of Opioids Prescription Drug Monitoring Programs (PDMP) state by state ■ Record of a patient’s controlled substance prescriptions ■ Some are available online 24/7 ■ Opportunity to discuss issues of over use of drugs with patient PDMP’s Provide warnings of potential misuse ■ Existing prescriptions not reported by patient ■ Multiple prescribers/pharmacies ■ Meds that increase overdose risk when taken together ■ Patient pays for controlled medications with cash ■ Prescribers can check their own prescribing History

PDMP Unsolicited Patient Threshold Reports ■ Reports automatically generated on patients who cross certain thresholds when filling prescriptions. Available in some states. ■ E-mailed to prescribers to whom prescriptions were attributed ■ Prescribers review records to confirm it is the patient of the prescribing physician and if the physician had written the prescription(s) attributed to them If PDMP Report is Inaccurate, ■ Contact PDMP If the physician wrote the prescription(s), patient safety may dictate need to discuss the patient with other prescribers listed on report ■ The physicians decide which of the prescribers will continue to prescribe for the patient & if they might address drug abuse concerns with the patient

Education of Patients and Families Prescription medicines should only be taken when prescribed to you or your family member by a provider ■ Taking a pill prescribed for someone else is unsafe and illegal, “even just once” ■ Misusing prescribed drugs can be as dangerous as illegal “street” drugs ■ Mixing prescribed opioids w/ alcohol or with sedatives / hypnotics is potentially fatal

Educate Parents: Not in My House Step 1: Monitor ■ Note how many pills in each prescription bottle or pill packet ■ Keep track of refills for all household members ■ If your teen has been prescribed a drug, coordinate & monitor dosages & refills ■ Make sure friends & relatives— especially grandparents—are aware of the risks ■ If your teen visits other households, talk to the families about safeguarding their medications Step 2: Secure Do not store prescription meds in the medicine cabinet Keep meds in a safe place (e. g. , locked cabinet) Tell relatives, especially grandparents, to lock meds or keep in a safe place Encourage parents of your teen’s friends to secure meds Step 3: Dispose Take inventory of all prescription drugs in your home Discard expired or unused meds

Prescribed Opioid Disposal Other Methods of Opioid Disposal ■ “Disposal Act” expands ways for patients to dispose of unwanted/expired opioids ■ If collection receptacle, mail-back program, or take-back event unavailable, throw out in household trash and take drugs out of original containers ■ Mix with undesirable substance, e. g. , used coffee grounds or kitty litter making it less appealing to children/pets, & unrecognizable to people who intentionally go through your trash ■ Place in sealable bag, can, or other container which prevent leaking or breaking out of garbage bag ■ Before throwing out a medicine container scratch out identifying info on label ■ Decreases amount of opioids introduced into the environment, particularly into water ■ Collection receptacles Call DEA Registration Call Center at 1 -800 -8829539 to find a local collection receptacle ■ Mail-back packages Obtained from authorized collectors ■ Local take-back events Conducted by Federal, State, tribal, or local law enforcement & partnering with community groups

Resources A Patient Prescriber Agreement (PPA) http: //www. namsdl. org/library/7440 DB 2 D-FE 8 C- 5 D 7183963097 CEEE 4 A 1 F/ For a list of treatment programs in this state: http: //americanaddictioncenters. org/rehab-guide/state-funded/#howto-find-state-funded-rehab SAMHSA substance use disorder treatment facility locator: http: //findtreatment. samhsa. gov/Treatment. Locator/faces/quick. Searc h. jspx SAMHSA substance use Mental Health treatment facility locator: http: //findtreatment. samhsa. gov/MHTreat ment. Locator/faces/quick. Search. jspx

MEDICATIONS USED TO TREAT OPIOID ADDICTION

Should medications be used in the treatment of addiction? ■ Is this a scientific question? ■ Is this a philosophical question? ■ Is this a practical question? Rationale for medication ■ Impact the physiology of addiction and dependence ■ Improve outcomes including retention and opioid use ■ Protect against lapses, which should be expected ■ Reduce high rates of relapse ■ Without medications >80% of heroin addicts relapse within 30 days after detoxification

Medications for the treatment of opioid addiction ■ Methadone – Full Agonist (See Note below) of Opioids ■ Buprenorphine(bupe) - Partial Agonist of Opioids - suboxone, subutex, zubsolv, bunavail ■ Extended release Naltrexone(XRNTX) – Antagonist of Opioids Vivitrol For Overdoses ■ Naloxone – Narcan NOTE: An agonist is a chemical that binds to a receptor and activates the receptor to produce a biological response. Whereas an agonist causes an action, an antagonist blocks the action of the agonist and an inverse agonist causes an action opposite to that of the agonist.

Effectiveness of medications for opioid addiction Methadone ■ Multiple clinical trials and meta-analyses (e. g. Cochrane) ■ Below 50% have 6 -month abstinence retention Buprenorphine ■ Multiple clinical trials and meta-analyses (e. g. Cochrane) ■ 50% have 6 -month abstinence retention Naltrexone ■ Limited effectiveness in pill form ■ Long acting injections and implants produce around 50% retention and sustained abstinence (e. g. Krupitsky et al. , 2011)

Relapse prevention medications Improve outcomes ■ Reduced Drug use ■ Reduced Mortality ■ Reduced Criminal behavior and recidivism ■ Reduced HIV and HCV transmission ■ Reduced Hospitalization ■ Reduced Homelessness ■ Reduced Psychiatric symptoms ■ Increased Employment ■ Increased Treatment retention ■ Decreased Downstream costs

Choice of medication: Methadone vs Buprenophine vs XR-NTX (extended release naltrexone) ■ Patient preference and family preference ■ Failure of other treatments, try something new ■ Side effects, anxious anticipation ■ Long acting duration of XRNTX ■ Methadone and bupe intrinsically reinforcing ■ Methadone and bupe relieve withdrawal early ■ All 3 relieve cravings ■ More familiarity with methadone and bupe, positive and negative reputation ■ Partial blockade for bupe, full blockade for XRNTX ■ Strong opioid effects for methadone, pros and cons ■ Problems with acceptability of agonists ■ More tools in the toolbox

Duration of treatment? ■ Is there an optimal duration? ■ Evidence so far suggests longer is better, but care should be individualized ■ Retention under real world conditions is problematic ■ No reason to suppose pre-imposed limitations helpful Relapse prevention medication Is the standard of care ■ But not everyone knows it yet ■ Persuading patients ■ Persuading families ■ Persuading criminal justice system ■ Persuading SUD providers, especially residential treatment ■ Persuading payers ■ Persuading the recovery community A house divided ■ Why do we have philosophy in our field? ■ Big tent, all recovery voices matter ■ Treatment choice selection bias ■ Follow up observational bias The power of language ■ “Drug-free” treatment ■ “Abstinence-based” treatment ■ Medication assisted recovery ■ Counseling-assisted medication ■ “Harm reduction” ■ Relapse-prevention medications ■ Anti-addiction medications

Is Relapse Prevention Medication Prescription just trading one addiction for another? DSM Criteria for Substance Dependence: A maladaptive pattern of use leading to clinically significant impairment or distress, manifested by 3 or > of the following in a 12 -month period: 1. Tolerance (increased amounts or diminished effects) 2. Withdrawal (withdrawal syndrome or use to relieve or avoid withdrawal) (Addictive Behaviors –loss of control) 3. Efforts or desire to cut down or control use 4. Taken Larger amounts or over a Longer period than intended 5. Social, recreational or occupational activities given up 6. Time spent in activities necessary to obtain the substance 7. Use despite Persistent or recurrent Physical or Psychological problems

Why medication? Can you be in recovery on medicines 1. Medicines just a crutch or Band-Aid – Maybe, Like meetings or groups. 2. If the patients like it so much, there must be something wrong with it. But if they don’t utilize treatment, it almost doesn’t matter how good it is. 3. If medications are an “easy fix” will patients refuse needed psychosocial treatments and supports. - Actually, they come to psychosocial treatment more. 4. If medications eliminate cravings will patients miss opportunity for needed cravings management? - Academic if they relapse. Postpone until later when stronger. Remains an open question -maybe need high intensity skill building later in treatment course. 5. Abuse and diversion - Real issue, needs to be managed, but not as problematic as scarey stories make it out to be. 6. What about spiritual recovery instead of medicines? - Why not both?

Limitations and unintended consequences Medications ■ Medication diversion ■ Inconsistency ■ Non-compliance ■ Dropout ■ Substandard practice ■ Side effects ■ Over-promising ■ Other substances

Additional adherence enhancements ■ Long acting formulations ■ Increased intensity and frequency of provider monitoring ■ Increased coordination and communication between medical and counseling staff ■ Role of concerned other in monitoring of adherence (eg: network therapy) ■ Supervised administration by caregiver or staff ■ Prescriptions left for counselor to distribute ■ Direct med administration up to daily

Integrated treatment: the role of nonmedication modalities ■ One concept: medications synergize counseling and other tools by increasing retention, utilization, time not using ■ Evidence mixed for benefit of counseling ■ One study: methadone alone < + counseling < + enhanced services (job counseling, family involvement, psychiatry, medical) (Mc. Lellanet al. JAMA. 1993; 269: 1953 -1959. ) ■ One study: no difference methadone with or without counseling (Schwartz et al. 2011. ) ■ Emerging consensus: enhancement value for many but not all, need matching and stepped strategies

Providing a full continuum of care ■ Inpatient detoxification and stabilization ■ Short term residential treatment ■ Long term residential treatment ■ Day treatment / partial hospitalization ■ Assisted living support for outpatient treatment (Individual Out Patient IOP “plus” Partial Hospitalization Program PHP “plus”) ■ Recovery housing

Treating Special Populations A. Pregnancy Unique opportunity and “motivational moment” Methadone and buprenorphine improve: ■ Maternal outcomes ■ Fetal outcomes Neonatal abstinence syndrome (NAS) ■ Manageable ■ Acceptable side effect Bupeless NAS, preference for mono product (subutex) Methadone better retention

Treating Special Populations B. Co-occurring psychiatric disorders Very common in patients with SUD Mood disorders especially common Outcomes improved with treatment reciprocally Most psychiatric medications compatible with relapse prevention medications with notable exception of sedative hypnotics C Initiation of buprenorphine as a pain treatment strategy At the transition from acute to chronic pain Longer term strategy for patients with a history of opioid addiction Possible transitional strategy for others As part of an overall comprehensive rehabilitative approach

Treating Special Populations D. Focus on youth This is a developmental disorder with adolescent onset Addressing the problem early will maximize impact Include and empower families to be part of the solution Developmental barriers to treatment engagement ■ Invincibility ■ Immaturity ■ Salience of burdens of treatment Variable effectiveness of family leverage (or not) vs family abdication Pushback against sense of parental dependence and restriction Prominence of co-morbidity

Bottom line on use of Medications to Treat Opioid Addiction ■ Relapse prevention medications for opioid addiction should be the standard of care ■ 3 good choices currently, more coming ■ Tailor medication and delivery and setting to individual patients ■ Some patients need more intensive support, structure, counseling, accountability; others not so much ■ Treatment works!!

What is Naloxone (Narcan)? Naloxone is opioid antagonist ■ NOTE: An agonist is a chemical that binds to a receptor and activates the receptor to produce a biological response. Whereas an agonist causes an action, an antagonist blocks the action of the agonist and an inverse agonist causes an action opposite to that of the agonist. Naloxone has High affinity for mu receptor ■ NOTE: Opioids exert their pharmacological actions through three opioid receptors, mu, delta and kappa whose genes have been cloned (Oprm, Oprd 1 and Oprk 1, respectively). Opioid receptors in the brain are activated by a family of endogenous peptides which are released by neurons.

What is Naloxone (Narcan)? ■ Displaces bound agonist ■ Prevents other agonists from binding ■ Works within minutes & Lasts 20 -90 mins ■ FDA approved for Intravenous (IV), subcutaneous (SC), intramuscular (IM) use ■ Recent FDA approved intranasal naloxone; also off-label intranasal use of naloxone for injection ■ Naloxone has been used for opioid reversal for 40 years in hospitals ■ Naloxone has been used for overdose in Emergency Departments and by paramedics for years ■ Since mid-1990 s, provision for use outside medical setting for people at risk of overdose

Opioid Overdose Prevention Programs(OOPP) ■ Started 1996, first program in Chicago ■ Started in harm prevention programs ■ OOPP train people at risk for overdose how to prevent overdose as well as how to recognize and respond to overdose ■ Participants are trained to seek help (call 911), rescue breath, administer naloxone IN or IM, and stay with the person who has overdosed

How to Train Participants in an Opioid Overdose Prevention Program before prescribing Naloxone Rescue Kits: ■ Have you ever had an accidental overdose? ■ What were the circumstances, what happened, how did you survive? ■ Have you ever witnessed an overdose? What did you do? ■ What do you do to protect yourself from overdose? ■ What are some risk factors for overdose? ■ Have you heard about naloxone/Narcan for reversal of overdose?

What is in a Rescue Kit? ■ Two doses of naloxone or devices ■ Two syringes or mucosal atomizing devices (MAD) ■ Instructions on use ■ May also include – Alcohol swabs – Face shields – Gloves

Resources Videos on Use of Naloxone LIVE! Using Injectable Naloxone to Reverse Opiate Overdose at: https: //www. youtube. com/watch? v=U 1 fr. PJo. Wtkw&feature=player_embedded Prescribe to Prevent: Prescribe Naloxone to Save a Life: http: //prescribetoprevent. org/patient-education/videos/ Instructional Website on Naloxone: http: //www. getnaloxonenow. org/index. aspx Providers’ Clinical Support System - For Medication Assisted Treatment Home of PCSS: http: //pcssmat. org/ Topics related to medication-assisted treatment for opioid use disorders. Webinars Current and Archived - PCSS-MAT offers live webinars on a variety of topics pertaining to identifying and treating opioid use disorders http: //pcssmat. org/webinars/

HOLISTIC APPROACHES TO PAIN MANAGEMENT AND TREATMENT OF SUBSTANCE USE DISORDERS INCLUDING OPIOIDS & HEROIN

Prologue There a number of Holistic approaches to treatment of substance use disorders including Opioid and Heroin Addiction. What follows is not an exhaustive list but a comprehensive summary of known Holistic Approaches being used at the current time in conjunction with Residential Treatment, 12 Step Programming, Evidence Based Psychotherapy and other long term interventions to address the overwhelming epidemic of the abuse of opioids, heroin and related substances.

Acupuncture is a part of East Asian medicine developed in China over 2, 500 years ago and currently practiced throughout Asia, Europe and the United States. Acupuncture is the insertion of fine needles into specific points on the surface of the body for the purpose of stimulating healing. Acupuncture may be a safe and feasible treatment to assist mothers to reduce their dosage of methadone (Janssen et al, 2012). Acupuncture was found to be as effective as relaxation training techniques for problems with anxiety, sleep or substance use or in reducing the need for further addiction treatment in patients with substance use problems and comorbid psychiatric disorders (Ahlberg, Skarberg, Brus & Kjellin, 2016).

References Ahlberg, R. Skårberg, K. , Brus, O. , & Kjellin, L. (2016). Auricular acupuncture for substance use: A randomized controlled trial of effects on anxiety, sleep, drug use and use of addiction treatment services. Substance Abuse Treatment, Prevention, and Policy, 11(24), DOI 10. 1186/s 13011 -016 -0068 -z Janssen, P. A. , Lou Demorest, L. C. , Kelly, A. , Thiessen, P. & Abrahams, R. (2012). Auricular acupuncture for chemically dependent pregnant women: A randomized controlled trial of the NADA protocol. Substance Abuse Treatment, Prevention, and Policy 7: 48 Videos Acupuncture - Back Pain Treatment - Full Version at: https: //www. youtube. com/watch? v=fq. Uu. Pka. HFDI Acupuncture Therapy to Relieve Stress and Sinus Issues | ASMR Triggers at: https: //www. youtube. com/watch? v=TC 4 l 0 Em. Nky. Y

Aromatherapy uses essential oils extracted from plants and herbs that can be inhaled or applied through the skin. Aromas derived from these natural plant sources have been shown in clinical studies to have positive effects on the mind and the body. These essential oils, which are composed of naturally occurring chemicals, can help to support emotional balance, a sense of calm, stress relief, and feelings of well-being. It is known that thinkin about the scent can be as powerful as the scent itself. Mentioning certain scents can bring about a deeper discussion of feelings and emotions, allowing the patient to tune into the experience more intimately, to feel it more directly, and to connect to it on a fuller level (La. Torre, 2003). Aromatherapy provides a potentially effective treatment for a range of psychiatric disorders appears to be without the adverse effects of many conventional psychotropic drugs (Perry & Perry, 2006).

References Perry, N. & Perry E. (2006). Aromatherapy in the management of psychiatric disorders: Clinical and neuropharmacological perspective. CNS Drugs, 20(4), 257 -280. La. Torre, M. A. (2003). Aromatherapy and the use of scent in psychotherapy. Perspectives in Psychiatric Care, 39(1), 35 -37. Video What is Aromatherapy? At: https: //www. youtube. com/watch? v=Qtd 2 Cu. Gga. D 4

Biofeedback is a scientific way of learning how to reduce tension. Biofeedback practitioners use instruments to give a person immediate feedback about the level of tension in their body. People practicing biofeedback often say they gain psychological confidence when they learn that they can control their physical reactions. Biofeedback has been found effective in several aspects of addiction treatment (Sokhadze, Cannon & Trudeau, 2008). Heart rate variability biofeedback (HRV BFB) is a clinical intervention that is gaining growing empirical support for the treatment of a number of psychological disorders, several of which are highly comorbid with substance use disorders (SUDs). The autonomic nervous system is the bases of two key processes implicated in the formation and maintenance of addictive pathology—affect dysregulation and craving—and it appears that HRV BFB may be an effective intervention to ameliorate autonomic nervous system dysregulation in these processes, and as such, prove to be an effective intervention for SUDs (Eddie et al, 2015 and Eddie et al 2014).

References Eddie, D. , Vaschillo, E. , Vaschillo, B. & Lehrer, P. (2015). Heart rate variability biofeedback: Theoretical basis, delivery, and its potential for the treatment of substance use disorders. Addiction Research & Theory, 23(4): 266– 272. DOI: 10. 3109/16066359. 2015. 1011625 Eddie, D. , Kim, C. , Lehrer, P. , Deneke, E. & Bates, M. E. (2014). A pilot study of brief heart rate variability biofeedback to reduce craving in young adult men receiving inpatient treatment for substance use disorders. Applied Psychophysiological Biofeedback, 39, 181– 192. DOI 10. 1007/s 10484 -014 -9251 -z Sokhadze, T. M. , Cannon, R. L. & Trudeau, D. L. (2008). EEG biofeedback as a treatment for substance use disorders: Review, rating of efficacy, and recommendations for further research. Applied Psychophysiological Biofeedback, 33, 1– 28 DOI 10. 1007/s 10484 -007 -9047 -5 Video What Is Biofeedback? Center for Brain Training's, Mike Cohen, Discusses Types of Biofeedback at: https: //www. youtube. com/watch? v=4 Sin 4 QR 4 cwo

Creative Arts Therapies Art Therapy – Dance Therapy – Drama Therapy – Poetry Therapy These creative therapies can be very helpful in the process of recovery from addiction. They offer the opportunity to get in touch with their inner self and with their higher power. These creative therapies can provide a form of expression for feelings that cannot be easily identified or put into words. Through helping the people with an addiction connect with their more authentic self, the expressive therapies can help raise self-esteem and provide an opportunity to create new experiences beyond habitual and painful emotional patterns. The creative arts foster a renewed ability to relax without drugs or alcohol (Oklan & Henderson, 2014). Art therapy has been empirically assessed as an effective form of relapse prevention for substance abusers who are relatively treatment resistant, defensive and unexpressive (Tam, Shik & Lam, 2016)

References Oklan, A. M. & Henderson, S. J. (2014). Treating inhalant abuse in adolescence: A recorded music expressive arts intervention. Psychomusicology: Music, Mind, and Brain, 24(3), 231– 237. doi. org/10. 1037/pmu 0000058 Tam, H. , Shik, A. W & Lam, S. S. (2016). Using expressive arts in relapse prevention of young psychotropic substance abusers in Hong Kong. Children & Youth Services Review. 60, 88 -100. DOI: 10. 1016/j. childyouth. 2015. 11. 022 Videos Dance/Movement Therapy, Mindfulness & Substance Abuse Recovery at: https: //www. youtube. com/watch? v=b 1 Yryise. VWY How Does Art Therapy Heal the Soul? | The Science of Happiness at: https: //www. youtube. com/watch? v=BN 2 r. Ta. FUlxs Dance/Movement Therapy & Mental Illness at: https: //www. youtube. com/watch? v=TIhp. Lsg. Q 1 is Dance/Movement Therapy at: https: //www. youtube. com/watch? v=qy 34 LAXF-R 0 An Insight Into Drama Therapy at: https: //www. youtube. com/watch? v=u. Zc 8 VPEus. KI Geri Chavis - author of "Poetry and Story Therapy: The Healing Power of Creative Expression" at: https: //www. youtube. com/watch? v=e. Taw. F 13 Bz. GM Welcome to Poetry Therapy at: https: //www. youtube. com/watch? v=Lzosdt. W-QVA

Equine-Assisted Therapy has been around for a long time. It was originally started as a therapy for people with physical disabilities and developmental disorders. It has been successfully used as part of the treatment for various psychological issues such as depression, anxiety, and eating disorders as well. People recovering from addiction have also been found to benefit from interactions with horses. This type of outdoor therapy experience combines the power of nature with the benefit of forming a relationship with an animal to help build confidence, trust, patience, and self-esteem. Some addiction treatment programs have seen results from the use of horses in treatment, particularly for younger patients, although most research evidence on equine therapy’s benefits has taken place outside of the substance use treatment field (ADAW, 2015). It is believed that Patients riding a horse can become familiar with the tools needed to get the horse to respond effectively, and that can translate for the patients to an understanding of the tools they need to stay grounded in recovery, from support meetings to daily meditations. Also, the “herd” dynamics that patients observe in how the horses interact with one another teach lessons about leading and following in life, everything observed in working with the horses is a tie-in to something else (ADAW, 2015). Four interrelated aspects of equine therapy, namely “change of focus”, “activity”, “identity”, and “motivation, ” suggest this therapy is more than just a break from usual SUD treatment. The stable environment is portrayed as a context where participants could construct a positive self: one which is useful, responsible, and accepted; more fundamentally, a different self from the “patient/self” receiving treatment for a problem (Kern-Godal et al. , 2016).

References ADAW (2015). Evidence grows for equine therapy as treatment engagement tool. Alcoholism & Drug Abuse Weekly, 27(41). DOI: 10. 1002/adaw Kern-Godal, A. , Brenna, I. H. , Arnevik, E. A. & Ravndal, E. (2016). More than just a break from treatment: How substance use disorder patients experience the stable environment in horseassisted therapy. Substance Abuse Research and Treatment, 10, 99– 108. doi: 10. 4137/SART. S 40475. Videos Horses Help Heal Veterans' Invisible Wounds | National Geographic at: https: //www. youtube. com/watch? v=Z 7 Eed. Cw. J 4 ww Horse Therapy: Addiction, Depression, and Suicide Prevention at: https: //www. youtube. com/watch? v=F 8 zlthz_t. DU Unexpected Miracles - Horses Healing Humans at: https: //www. youtube. com/watch? v=Un. Ogqy. R 9 kr 8

Gardening Being in nature is known, in and of itself, to have a healing effect on the mind and emotions. Gardening as a form of therapy has increasingly been used as an approach to addiction and mental health treatment. Healing gardens are often a part of addiction treatment centers, long term care facilities and other healthcare settings. Gardening can help to lower stress, boost self-confidence, build teamwork, and foster perseverance. The rewards are both immediate and long term as one sees the plants and garden develop and change with the seasons. This can be as simple as having some potted herbs or plants in one's home; becoming part of a community garden; or cultivating one's own vegetable or flower garden on one's roof if allowed or at one's home. Gardening promotes a new self-concept and gardening helps emotional and behavioral managemen (Twill, Purvis & Norris, 2011). Research has shown that patients participating in gardening programs resulted in experiencing reduced stress and depression, in addition to improving the quality of their lives (Detweiler, et al. , 2015).

References Detweiler, M. B. , Self, J. A. , Lane, S. Spener, L. , Lutgens, B. , Kim, D. Y. , Halling, M. H. , Rudder, T. F. , & Lehmann, L. (2015). Horticultural therapy: A pilot study on modulating cortisol levels and indices of substance Craving, posttraumatic stress disorder, depression, and quality of life in veterans. Alternative Therapies, 21(4), 36 -41 Twill, S. E. , Purvis, T. & Norris, M. (2011). Weeds and seeds: Reflections from a gardening project for juvenile offenders. Journal of Therapeutic Horticulture, 21(1), 7 -17. Videos Mental Health Center of Denver Horticulture Therapy Program at: https: //www. youtube. com/watch? v=AA-7 o. WBZU 6 Y Horticulture Therapy Heals the mind body and spirit at: https: //www. youtube. com/watch? v=w. WTZ 7 Icky. Tw

Guided Imagery involves the use of the imagination to achieve specific healing and life goals. It can be effective in helping people cope with stress and regain a sense of control and well-being. As with all other mind/body techniques, interest, motivation and practice are keys to the successful use of guided imagery for health and healing. Guided imagery is considered a nonpharmacologic modality as well as complementary and alternative medicine, and involves imagining scenes, pictures, or experiences to help the body heal from pain (Burhenn et al. , 2014). It was found that incorporating guide imagery and other holistic therapies helped patients reduce opiate use. While some patients found other physicians to give them the opiates they desired, those who persisted in an environment of respect and acceptance significantly reduced opiate consumption compared with patients in conventional care. While resistant to complementary and alternative medicine therapies initially, the majority of patients came to accept and to appreciate their usefulness (Mehl-Madrona, Mainguy & Plummer, 2016). Stress Management techniques utilizing guide imagery were found to reduce pain for those suffering from chronic neck pain (Metikaridis et al. , 2017).

References Burhenn, P. , Jill Olausson, J. Villegas, G. & Kravits, K. (2014). Guided imagery for pain control. Clinical Journal of Oncology Nursing, 18(5), 501 -503. DOI: 10. 1188/14. CJON. 501 -503 Mehl-Madrona, L. , Mainguy, B. & Plummer, J. (2016) Integration of complementary and alternative medicine therapies into primary-care pain management for opiate reduction in a rural setting. Journal of Alternative & Complementary Medicine, 22(8), 621 -626. DOI: 10. 1089/acm. 2015. 0212 Metikaridis, D. , Hadjipavlou, A. , Artemiadis, A. , Chrousos, G. , & Darviri, C. (2017). Effect of a stress management program on subjects with neck pain: A pilot randomized controlled trial. Journal of Back & Musculoskeletal Rehabilitation, 30(1), 23 -33. DOI: 10. 3233/BMR-160709 Videos Guided Meditation For Anxiety & Stress, Beginning Meditation, Guided Imagery Visualization at: https: //www. youtube. com/watch? v=6 v. O 1 w. PAmi. MQ Calming our minds: Relaxing music & Affirmations for a Peaceful life & Relaxation at: https: //www. youtube. com/watch? v=t. OQa. VSX-N 4 c Releasing Negative Thoughts Spoken Affirmations for a peaceful, calm positive mind at: https: //www. youtube. com/watch? v=8 m. SJ 4 u. KRBf 0

Herbal Therapy Herbs are natural plant substances that have a variety of effects on the body. Many herbs have long been used in detoxification. Kudzu has the potential for moderating alcohol abuse. Kava and valerian can be used to treat the insomnia that accompanies withdrawal. Milk thistle has been shown to improve liver function. The use of herbs in the recovery process may be most effective when combined with other strategies that support the whole person including nutrition, bodywork, acupuncture, relaxation and exercise (Behere, Muralidharan & Benegal, 2009). It has also been demonstrated that there is a link of the action of herbs or acupuncture to the neurotransmitters system implicated in alcohol dependence (Liu, Lawrence & Liang, 2011).

References Behere, R. V. , Muralidharan, K. & Benegal, V. (2009). Complementary and alternative medicine in the treatment of substance use disorders—a review of the evidence. Drug and Alcohol Review, 28, 292– 300. DOI: 10. 1111/j. 1465 -3362. 2009. 00028. x Liu, Q, Lawrence, A. J. & Liang, J. H. (2011). Traditional Chinese medicine for treatment of alcoholism: From ancient to modern. The American Journal of Chinese Medicine, 39(1), 1– 13. DOI: 10. 1142/S 0192415 X 11008609 Video Top 10 Natural Pain Killers at: https: //www. youtube. com/watch? v=g. NXr. Rljjg. W 8

Homeopathy is a non-toxic, gentle system of medicine that uses highly-diluted remedies to treat illness and relieve discomfort in a wide variety of health conditions. It is thought that homeopathic remedies are able to stimulate a person’s bodily systems to deal with stress and illness more efficiently. Research is currently being undertaken to understand how and why these remedies work on the mental and physical level. Specific homeopathic remedies may be helpful during the period of withdrawal from alcohol or drugs. Homeopathy is practiced by licensed physicians and other qualified prescribers in many parts of the world, including Europe, Asia, and the U. S. While self-care with homeopathy can be helpful for minor short-term illnesses and injuries, if an illness or condition is chronic or serious, it is best to consult an experienced prescriber for a remedy that more accurately meets an individual’s health needs. It has been difficult to research the effectiveness of Homeopathy with mental health and substance abuse disorders, but results of such studies support its use with these disorders (Adler et al. , 2011). Alcoholism is one of the world's costly drug use problem. In addition, an alcoholic can develop multiple forms of addiction to alcohol simultaneously such as psychological, metabolic, and neurochemical. This behavior interferes with the alcoholic's normal personal, family, social, or work life. Here the best way of Homeopathic mode of treatment is to treat the patient by giving constitutional medicine along with moral support (Gupta & Shah, 2015). The therapeutic potential of perispinal injection for CNS disorders is highlighted by the rapid neurological improvement in patients with otherwise intractable neuroinflammatory disorders that may ensue following perispinal etanercept administration (Tobinick et al. , 2012 & Tobnick et al. , 2014, & Tobinick, 2016).

Hypnosis is a calm natural state of focused attention which can be produced by one's self or with the help of a therapist. From that state, the mind is especially receptive to ideas and suggestions compatible with the person's goals. Some people have found hypnosis to be a useful part of a total recovery program. It has been used in dealing with patients who are wanting to stop drinking with some success (Jayasinghe, 2005). Hypnosis allows the patients reinvestment their senses, as well as a modification of their relationship with the outside world. This helps them to change and start a process of opening up and letting go of their addicting behaviors (Kammoun et al. , 2009).

References Adler, U. C. , Kruger, S. , Teut, M. , Ludtke, R. Bartsch, I. , Schutzler, L. , Melcher, F. , Wilich, S. N. , Linde, K. & Witt, C. M. (2011). Homeopathy for depression - DEP-HOM: study protocol for a randomized, partially double-blind, placebo controlled, four armed study. Trials, 12, 43. doi: 10. 1186/1745 -6215 -12 -43 Gupta, D. K. & Shah, P. (2015). Treating alcoholism in the global era by homeopathy. National Journal of Integrated Research in Medicine, 6(2), 117 -120. Tobinick, E. , Kim, N. M. , Reyzin, G. , Rodriguez-Romanacce, H. & De. Puy, V. (2012). Selective TNF inhibition for chronic Stroke and traumatic brain injury: An observational study involving 629 consecutive patients treated with perispinal etanercept. CNS Drugs 26, 1051 -1070. DOI 10. 1007/S 40263 -0120013 -2 Tobinick, E. , Rodriguez-Romanacce, H. , Levine, A. , Ignatowski, T. A. & Spengler, R. N. (2014). Immediate Neurological Recovery Following Perispinal Etanercept Years After Brain Injury. Clinical Drug Investigations, 34, 361– 366. DOI 10. 1007/s 40261 -014 -0186 -1 Tobinick, E. (2016). Perispinal delivery of CNS drugs. CNS Drugs, 30(6), 469 -480. DOI: 10. 1007/s 40263 -016 -0339 -2 Videos Homeopathic Remedies for Back Pain at: https: //www. youtube. com/watch? v=f 4 sd 2 ks 2 d 7 w Immediate relief after 2 years of severe constant pain 480 p at: https: //www. youtube. com/watch? v=v. P 6 Nw 1_OGIg (Tobinick et al. , 2012 & Tobnick et al. , 2014,

Journaling Writing in a personal journal is an excellent tool for self-reflection, charting your progress, recording your daily experiences and thoughts, and identifying your goals, habit patterns, conflicts and gratitude. It can help you express your thoughts and explore and clarify any issues you may be dealing with in a private way. The Tools for Coping Books on www. coping. us all utilized Journaling at the end of each of their chapters to encourage their readers to progress in their recovery efforts. Bibliotherapy and journaling have been identified as recovery tools with African Americans with substance use disorders (Johnson, 2012). In another research project, participants intended to drink significantly fewer drinks per week and engage in marginally fewer heavy drinking occasions after writing about a negative drinking occasion in their journal writing exercises (Young, Rodriguez & Neighbors, 2013).

References Johnson, M. (2012). Bibliotherapy and journaling as a recovery tool with African Americans with substance use disorders. Alcoholism Treatment Quarterly, 30(3), 367370. DOI: 10. 1080/07347324. 2012. 691042 Young, C. M. , Rodriguez, L. M. & Neighbors, C. (2013). Expressive writing as a brief intervention for reducing drinking intentions. Addictive Behaviors, 38(12), 2913 -2917. DOI: 10. 1016/j. addbeh. 2013. 08. 025 Videos Journaling for Depression at: https: //www. youtube. com/watch? v=RLPTkb. Bjw. O 4 Battling Bipolar Disorder: Journaling for Mental Health at: https: //www. youtube. com/watch? v=z. THk 1 F-a 7 Cw

Massage and Bodywork Massage and bodywork address the mind/body/spirit, offering the possibility of healing and change on many levels. On a physical level, it can facilitate the release of tension and holding and improve energy balance and flow. It also offers the opportunity to explore deeper levels of relaxation and peace, greater selfacceptance and awareness, and a deeper connection to self and others. Management of non-specific neck pain disorders often include massage therapy as well as exercise therapy intervention or promotion which have been found to be effective non-pharmaceutical treatments (Skillgate et al. , 2015). Patients with severe pain were found after massage therapy, to report highly significant improvement in their levels of distress, pain, tension, discomfort, and mood compared with their premassage ratings (Suresh et al, 2008).

References Skillgate, E. , Bill, A. S. , Cote, P. , Viklund, P. , Peterson, A. & Holm, L. W. (2015). The effect of massage therapy and/or exercise therapy on subacute or long-lasting neck pain - the Stockholm neck trial (STONE): Study protocol for a randomized controlled trial. Trials, 16, 414. DOI 10. 1186/s 13063 -015 -0926 -4 Suresh, S. , Wang, S. , Porfyris, S. , Kamansinski-Sol, R. & Steinhorn, D. M. (2008). Massage therapy in outpatient pediatric chronic pain patients: do they facilitate significant reductions in levels of distress, pain, tension, discomfort, and mood alterations? Pediatric Anathesia, 18. 884 -887. doi: 10. 1111/j. 1460 -9592. 2008. 02638. x Video What's The Difference Between A Massage & Bodywork at: https: //www. youtube. com/watch? v=s 0 U 2 p. BCs. C 0 I

Meditation has roots in many spiritual traditions, including Hinduism, Buddhism, Islam, Judaism, and Christianity. Meditation emerged in each case as a spiritual practice to discipline the mind and deepen spiritual awareness. There is an ongoing call for the incorporation of spirituality into the world of substance abuse treatment and the use of meditation seems to be responsive to this call (Horton & Naelys, 2016). Today meditation is also practiced for stress management, personal growth, general wellness, and its therapeutic effects for medical and emotional difficulties. The most recent boost to meditation comes from the mindfulness meditation movement, derived from Vipassana in Buddhism but presented in Western form by Jon Kabat-Zinn and others (Moss, 2011). An abundance of empirical research studies has now emerged documenting specific benefits from mindfulness meditation and meditation in general. There are many different types of meditation which all work to slow down the chatter of the mind and promote relaxation and mental clarity. Benefits of these age-old techniques of healthy living have been shown to persuasively to promote resilience and better mental health (Hazri & Sakar, 2014).

Mindfulness Helps one to tap into the present moment – for relaxation and reduction of stress in any situation: at home, at the office or school, while driving, and while shopping. Mindfulness has been found to reduce opioid cue-reactivity while restructuring natural reward processing and provides preliminary support for the hypothesis that behavioral interventions may ameliorate craving by enhancing reward responsiveness (Garland, Froeliger, & Howard, 2014). Also recent study has demonstrates preliminary feasibility and efficacy of Mindfullness Meditation as a treatment for co-occurring prescription opioid misuse and chronic pain (Garland, Manusov, Froeliger, Kelly, Williams & Howard, 2014). Providing training and promoting mindfulness as an effective factor for the treatment and reduction of detrimental impacts of addiction can be a major step toward treatment of dependency on drugs and its individual and social impacts. Through providing adequate trainings to patients, the addiction intensifying factors can be harnessed, preventive measures can be strengthened, and the forthcoming detrimental outcomes can be prevented (Imani, et al, 2016).

Transcendental Meditation The long-term positive effects of Transcendental Meditation seems to be correlated with a reduced relapse rate. Transcendental Meditation may not only reduce tension and anxiety, but also enhance a sense of control in anxiety-provoking situations that strengthens the long-term resistance to stress. Transcendental Meditation (TM) program has been recommended for improving soldier resilience, and as a viable adjunctive treatment option for PTSD and Anxiety (Barnes, Monto, Williams & Rigg, 2016).

References Barnes, V. A. , Monto, A. , Williams, J. J. , & Rigg J. L. (2016). Impact of transcendental meditation on psychotropic medication use among active duty military service members with anxiety and PTSD. Military Medicine, 181(1), 56 -63. doi: 10. 7205/MILMED-D-14 -00333 Garland, E. L. , Froeliger, B. & Howard, M. O. (2014). Effects of mindfulness-oriented recovery enhancement on reward responsiveness and opioid cue-reactivity. Psychopharmacology, 231, 3229– 3238. DOI 10. 1007/s 00213 -014 -3504 -7 Garland, E. L. , Manusov, E. G. , Froeliger, B. Kelly, A. , Williams, J. M. , & Howard, M. O (2014). Mindfulnessoriented recovery enhancement for chronic pain and prescription opioid misuse: Results from an earlystage randomized controlled trial. Journal of Consulting and Clinical Psychology, 82(3), 448– 459. DOI: 10. 1037/a 0035798 Hazari, N. & Sakar, S. (2014) A Review of yoga and meditation neuroimaging studies in healthy subjects. Alternative and Complementary Therapies, 20(1), 16 -26. DOI: 10. 1089/act. 2014. 20109 Horton, E. G. & Naelys, L. (2016) Spirituality in the treatment of substance use disorders: Proposing the Three-legged Stool as a model for intervention. Journal of Religion & Spirituality in Social Work, 35(3), 179 -199. DOI: 10. 1080/15426432. 2015. 1067585 Imani, S. , Vahid, M. K. A. , Gharraee, B. , Noroozi, A. , Habibi, M. & Bowen, S. (2016). Effectiveness of mindfulness-based group therapy compared to the usual opioid dependence treatment. Iranian Journal of Psychiatry, 10(3), 175 -184

Moss, D. (2011). Special issue: Yoga, meditation, and applied psychophysiology Biofeedback, 39, (2), 43– 44. DOI: 10. 5298/1081 -5937 -39. 2. 11 Videos How can mindfulness change your life - Jon Kabat Zinn at: https: //www. youtube. com/watch? v=EJjyrzqk. Xr. E 9 Attitudes - Jon Kabat Zinn at: https: //www. youtube. com/watch? v=2 n 7 FOBFMv. Xg&feature=emsubs_digest-vrecs Jon Kabat-Zinn: Body Scan at: https: //www. youtube. com/watch? v=D 8 o. KWQi. EWYs Mindfulness for Beginners by Jon Kabat Zinn Audiobook at: https: //www. youtube. com/watch? v=ea. L 24 Ppn_f. M&feature=em-subs_digest-vrecs The Science And Spirituality Of Meditation – Documentary at: https: //www. youtube. com/watch? v=s 7 Trf. Tu. D 9 Q 4 Meditation Music for Positive Energy - Relax Mind Body | Spiritual Awakening Music at: https: //www. youtube. com/watch? v=URWss 3 Ezp. VQ Meditation Music for Positive Energy l Clearing Subconscious Negativity l Relax Mind Body at: https: //www. youtube. com/watch? v=-1 bl 9 H 9 b. NPA

Music Therapy Music can have a powerful effect on emotions and mood. It can be a vehicle for self-expression and can help create peaceful and calm feelings. As such, it can be a valuable tool for people working to overcome an addiction. Music therapy can help people process emotions and supports personal growth important to overcoming addictions. Research into the effect of group improvisational music therapy on depression in adolescents and adults with substance abuse was investigated music therapy relieved their depressive symptoms (Albornoz, 2011). Use of Music therapy with postoperative patients resulted in them experiencing enhanced pain management and environmental noise satisfaction (Commeaux & Steele-Moses, 2013). But even just listening to music on your own or creating music can have some important benefits. It can help: (1) Release or calm the emotional highs and lows people often feel when they first become sober, (2) Manage stress levels - listening to or creating music can be a wonderful way to destress, (3) Relieve a sense of boredom that is often felt in early recovery and (4) Increase enjoyment and reduce feelings of loneliness which can lessen the stress of recovery

References Albornoz, Y. (2011). The effects of group improvisational music therapy on depression in adolescents and adults with substance abuse: A randomized control trail. Nordic Journal of Music Therapy, 20(3), 208 -224. doi. org/10. 1080/08098131. 2010. 522717 Comeaux, T. & Steele-Moses, S. (2013). The effect of complementary music therapy on the patient's postoperative state anxiety, pain control, and environmental noise satisfaction. Medical Surgical Nursing, 22(3), 313 -318. Videos Music Therapy & Emotions for Depression, Stress & Mental Health Issues at: https: //www. youtube. com/watch? v=I 1 R-r-VBy. SY Music Therapy to Relax Before Sleep: Let go of Stress, tension, anxiety relief at: https: //www. youtube. com/watch? v=Hj. Dk. Qf. SPBk. A

Neurofeedback (also called Brain wave biofeedback) is a therapy in which patients learn to change their brain wave patterns. Changing brainwaves can have a beneficial effect on relaxation and reduce stress and its unhealthy impact on the brain and nervous system. In one type of neurofeedback the training involves normalization of alpha and theta brain waves which are disturbed by long term substance abuse. Neurofeedback has shown dramatic success in several studies in preventing relapses from drug and alcohol addiction. Neurofeedback is considered an excellent therapeutic tool for treating substance abuse conditions and for treating disorders. Although it has been used primarily in treating attention deficit disorders, neurofeedback is seen as beneficial in the treatment of many conditions affecting thought processes (ADAW, 2010). The Flexyx Neurotherapy System (FNS), a novel variant of EEG biofeedback, was adapted for intervention with seven treatment-refractory Afghanistan/Iraq war veterans, and brought about significant decreases in bothersome neurobehavioral and posttraumatic stress symptoms. FNS may help ameliorate mixed trauma spectrum syndromes Nelso & Esty, 2012).

References ADAW (2010). Neurofeedback: Fact or fiction. Alcoholism & Drug Abuse Weekly. 22, DOI: 10. 1002/adaw Nelson, D. V. & Esty, M. L. (2012). Neurotherapy of traumatic brain injury/posttraumatic stress symptoms in OEF/OIF veterans. The Journal of Neuropsychiatry and Clinical Neurosciences, 24(2), 237– 240. Video What Is Neurofeedback? How Brain Training Can Benefit Kids, Families, and Adults at: https: //www. youtube. com/watch? v=Hx. HR 7 In. SQ 1 c

Nutrition In dealing with the chemical imbalances that are both a cause of substance abuse and a result of long-term substance addiction, nutritional therapy can be helpful in several ways. It has been found that there is a strong relationship between sugar addiction and alcoholism. Eliminating certain substances such as sugars and simple starches and increasing protein intake can help to rebalance brain chemistry. Good nutrition can also help heal damage to the body caused by the depletion of nutrients common in substance abuse. Use of nutritional Supplements, Vitamins and Herbs helps restore the proper biochemical balance in the brain. Research has found that nutrition education is an essential component of substance abuse treatment programs and can enhance substance abuse treatment outcomes. For this reason, nutrition education, should be incorporated into substance abuse treatment programs (Grant, Haughton & Sachan, 2004). Supporting this point of view is that indications are that drug abuse may increase the risk of the metabolic syndrome because Drug-abusing patients have higher rates of diabetes complications and Substance abuse is a significant contributing factor for treatment noncompliance in diabetes and finally Nutrition education can enhance substance abuse treatment outcomes (Virman et al. , 2007)

References Grant, L. P. , Haughton, B. & Sachan, D. S. (2004). Nutrition education is positively associated with substance abuse treatment program outcomes. Journal of the American Dietetic Association 104(4), 604 -610. DOI: 10. 1016/j. jada. 2004. 01. 008 Virmani, A. Binienda, Z. K. , Ali, S. F. & Gaeani, F. (2007) Metabolic syndrome in drug abuse. New York Academy of Sciences, 1122, 50– 68. doi: 10. 1196/annals. 1403. 004 Videos 24 Anti Inflammatory Foods with Crazy Powerful Healings Benefits at: https: //www. youtube. com/watch? v=qii. MWKTep 2 U How to Avoid Inflammatory | 7 Foods You Should Avoid That Cause Inflammation at: https: //www. youtube. com/watch? v=nxr. BTAts. E 1 U

Pet Therapy Animal-assisted therapy is being used in a wide variety of settings to help people with acute and chronic illnesses. This is based on the many physical and psychological benefits seen in patients when they interact with animals. These include lowered blood pressure and heart rate, increased beta-endorphin levels (a hormone produced by the brain and nervous system that reduces pain), decreased stress levels, reduced feelings of anger, hostility, tension and anxiety, improved social functioning, and increased feelings of empowerment, trust, patience and self-esteem. Animal therapy is looked upon as both a learning and healing experience. It has been demonstrated that simple presence of a dog was beneficial for reducing stress levels in stressed adults (Gonzalez-Ramierz et al, 2013). Literature has shown that animals’ presence, spontaneous behaviors and availability for interaction may facilitate therapy. It has been demonstrated that interactions with a friendly animal can result in reducing levels of cortisol and increasing oxytocin, dopamine, endorphins and phenethylamine (Abreau & Figueiredo, 2015).

References Abreu, T. & Figueiredo, A. R. (2015). Paws for help – Animal-assisted therapy. European Psychiatry. Supplement 1, 30, 1651 -1651. DOI: 10. 1016/S 0924 -9338(15)31274 -8 González-Ramírez, M. T. , Ortiz-Jiménez, X. A. , & Landero-Hernández, R. (2013). Cognitive– behavioral therapy and animal-assisted therapy - Stress management for adults. Alternative and Complementary Therapies 19(5), 270 -275. DOI: 10. 1089/act. 2013. 19505 Videos Animal Assisted Therapy at: https: //www. youtube. com/watch? v=J 1 y. A_j. Pcj. Eo Animal Assisted Therapy: How Pet Therapy Works at: https: //www. youtube. com/watch? v=YW 52 mdo. I-W 8

Tai chi and Qigong There are many ways to achieve a meditative state of mind. For those who have trouble sitting quietly for periods of time, various movement practices and martial arts, such as tai chi, qigong, and karate, can focus and calm the mind and enhance feelings of self-confidence and self-worth. Tai chi - has been found in a recent study to be a promising exercise that improves quality of life for individuals with stimulant dependence (Dong et al. , 2016). Qigong - is a traditional Chinese health practice for mind and body wellness. It integrates slow movement, a relaxed posture, a focus on breathing, and a clear and calm state of mental awareness. It is considered a form of exercise called “moving meditation". Qigong meditation appears to contribute positively to addiction treatment outcomes, with results at least as good as those of an established stress management program. Results for those who meditate adequately are especially encouraging. Meditative therapy may be more effective or acceptable for female drug abusers than for males. (Chen, Comerford, Shinnick, & Ziedonis, 2010). A recent study showed that internal Qigong generated benefits on treating some chronic pain with significant differences (Bai et al, 2015).

References Bai, Z. , Guan, Z. , Fan, Y. Liu, C. , Yang, K. , Ma, B. & Wu, B. (2015). The effects of Qigong for adults with chronic Pain: Systematic review and meta-analysis. The American Journal of Chinese Medicine, 43(8), 1525– 1539. DOI: 10. 1142/S 0192415 X 15500871 Chen, K. W. , Comerford, A. , Shinnick, P. & Ziedonis, D. M. (2010). Introducing Qigong meditation into residential addiction treatment: A pilot study where gender makes a difference. The Journal of Alternative and Complementary Medicine, 16(8), 875– 882. DOI: 10. 1089/acm. 2009. 0443 Dong, Z. , Ding, X. , Guobin, D. , Fei, W. , Xin, X. , & Daoxin, Z. (2016). Beneficial effects of Tai Chi for amphetamine-type stimulant dependence: a pilot study. American Journal of Drug & Alcohol Abuse, 42 (4), 469 -478. DOI: 10. 3109/00952990. 2016. 1153646 Videos Daily Tai Chi - join in this 8 -minute exercise at: https: //www. youtube. com/watch? v=PNt. Wq. Dxww. Mg Tai Chi Secret: Increase mental clarity + relaxation at: https: //www. youtube. com/watch? v=fh. T 178 k 0 Fh. A "Deep Meditation Music": Music for Qigong, Tai Chi, Massage, Meditation Music, Motivational ♫ 231 at: https: //www. youtube. com/watch? v=0 Yg. M 0 r 5 Mt 6 E

YOGA Yoga emerged within the history of Hinduism in India and evolved as it spread across Asia and later into North America and Europe. Originally a comprehensive system for spiritual and personal awareness and discipline, integral to the Indian culture and to its spiritual heritage, today yoga is practiced for physical fitness, weight management, and general wellness and increasingly for its well documented therapeutic effects for medical and emotional problems (Moss, 2011). Yoga is a technique that uses physical postures and controlled breathing to lengthen and strengthen the spine, increase flexibility, calm the mind, improve concentration, and promote patience. Yoga can also contribute to a greater sense of control in more acute states when experiencing cravings, insomnia, agitation, etc. Regular practice is needed to fully experience these benefits. Benefits of these age-old techniques of healthy living have been shown to persuasively to promote resilience and better mental health (Hazri & Sakar, 2014). The utility of Yoga/Meditation as a simple, safe, and inexpensive format to improve the quality of life in a population that has many medical difficulties and extenuating stressors has been demonstrated (Agarwai, Kumar & Lewis, 2015). A recent study found that long-term practice of Sahaja Yoga Meditation is associated with larger grey matter volume overall, and with regional enlargement in several right hemispheric cortical and subcortical brain regions that are associated with sustained attention, self-control, compassion and interoceptive perception. The increased grey matter volume in these attention and self-control mediating regions suggests use-dependent enlargement with regular practice of this meditation (Hernandez et al, 2016).

References Agarwal, R. P. Kumar, A. & Lewis, J. E. (2015). A pilot feasibility and acceptability study of yoga/meditation on the quality of life and markers of stress in persons living with HIV who also use crack cocaine. The Journal of Alternative and Complementary Medicine, 21(3), 152– 158. DOI: 10. 1089/acm. 2014. 0112 Hazari, N. & Sakar, S. (2014) A Review of yoga and meditation neuroimaging studies in healthy subjects. Alternative and Complementary Therapies, 20(1), 16 -26. DOI: 10. 1089/act. 2014. 20109 Hernández, S. E. , Suero, J. , Barros, A. , González-Mora, J. L. , & Rubia, K. (2016). Increased grey matter associated with long-term Sahaja yoga meditation: A voxel-based morphometry study. PLo. S ONE 11(3): doi: 10. 1371/journal. pone. 0150757 Moss, D. (2011). Special issue: Yoga, meditation, and applied psychophysiology Biofeedback, 39, (2), 43– 44. DOI: 10. 5298/1081 -5937 -39. 2. 11 Videos Yoga and Mental Health: Happiness & Its Causes at: https: //www. youtube. com/watch? v=m. Dm 9 ur. VY 6 IA How Yoga Can Improve Our Mental Health at: https: //www. youtube. com/watch? v=JAu. FPra. Fz-c What are the Benefits of Yoga? At: https: //www. youtube. com/watch? v=CU 3 Hu. PNsy. G 4 Yoga and Mental Health at: https: //www. youtube. com/watch? v=BMFv. I 2 SLF 60

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