NEUROBIOLOGY OF YOGA IN DE-ADDICTION

Presenter:

Dr Sumana V. BNYS, MD in Clinical Yoga

Research Associate

NIMHANS Integrated Centre for Yoga

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Substance abuseSubstance abuse refers to the harmful or hazardous use of psychoactive substances, including alcohol and illicit drugs.

Dependence Syndrome

Strong desire to take the

drug

Difficulties in controlling

its use

Persisting in its use despite

harmful consequences

A higher priority given to drug use

than to other activities and obligations

Increased tolerance

Sometimes a physical

withdrawal state

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Terminologies• Substance - Any Drugs, Medication, or Toxins that shares the potential of

abuse.

• Abuse - Maladaptive pattern of Substance use that impairs health in aboard sense.

• Addiction - Physiological & psychological dependence on substance ofabuse that affects the CNS in such a way that withdrawal symptoms areexperienced when the Substance is discontinued.

•Dependence Syndrome – A cluster of physiological, behavioral &cognitive phenomena induced by the repeated taking of a Substance.

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Characteristics of Dependence Syndrome• Compulsion or a strong desire to take the substance.

• Difficulties in controlling substance taking behaviour in terms of its onset, termination or levelsof use

• Physiological Withdrawal state is when a group of signs & symptoms occurs when a drug isreduced in amount or withdrawn or use of same drug with the intention of relieving or avoidingwithdrawal symptoms

• Tolerance is a state in which after repeated administration of a particular drug, effect producedby it is decreased, or requires increasing doses to produce the same effect.

• Progressive neglect of alternative pleasures or interests because of drug use and increasedamount of time spent on taking drugs or recovery from its effects.

• Persistent use of drugs despite the clear evidence or harmful consequences on health.

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Classification

Mental and behavioral disorders due to use of…

F10 – …Alcohol

F11 – …Opioids

F12 – …Cannabinoids

F13 – …Sedatives & Hypnotics

F14 – …Cocaine

F15 – …other Stimulants, including Caffeine

F16 – …Hallucinogens

F17 – …Nicotine

F18 – …Inhalants

F19 – …Psychoactive Substances

ALCOHOLTOBACCO

COCAIN

HALLUCINOGENSOPIOIDS

CAFFEINE CANNABISINHALANTS

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Aetiology

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AetiologyBIOLOGICAL FACTORS:

❖ Family history of Substance use disorders

❖ Genetic factors

ENVIRONMENTAL FACTORS:

❖ Structural factors

❖ Proximal factors

❖ Distal factors

❖ Stress

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AetiologySOCIOCULTURAL FACTORS:

❖ Cultural and ethnic background

❖Media/Advertising

❖ Childhood trauma

❖ Learning disorders

COMORBID FACTORS:

❖Antisocial personality disorder

❖Depression

❖Suicidal behaviour

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AetiologyDEVELOPMENTAL FACTORS:

❖ Adolescence vs Later age

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Aetiology

National Epidemiologic survey by the National Institute on Drug Abuse, 2003 Survey by the National Commission for Protection of Child Rights

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AetiologyPSYCHOLOGICAL FACTORS

❖General Rebelliousness

❖Sense of Inferiority or Low Self-Esteem

❖Poor Impulse Control

❖Loneliness, Unmet needs

❖Desire to escape from reality

❖Desire to experiment, a sense of Adventure, Pleasure Seeking

EASY AVAILABILITY OF DRUGS

❖Taking Drugs Prescribed by the Doctors (Eg: Benzodiazepine Dependence)

❖Taking drugs that can be bought legally without Prescription (Eg: Nicotine, Opioids)

❖Taking Drugs that can be Obtained from illicit Sources (Eg: Street Drugs)

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AetiologyBEHAVIORAL THEORIES

❖ Conditioning / Cumulative reinforcement from drug use.

❖ Drug use causes euphoric experience

❖ Stimuli & Setting associated with drug use

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Stages of AddictionDrug addiction has 2 aspects

1. Impulse control

2. compulsive disorders.

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Stages of Addiction

Binge/ Intoxication stage

Withdrawal/ Negative affect

Preoccupation/ Anticipation (craving)

Acute reinforcement/ social drinking

Recovery??

Relapse!!!

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Neurobiological mechanisms of the binge/intoxication stage❖ Reward circuit

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Neurobiological mechanisms of the binge/intoxication stage❖ Activation of D1 dopamine receptor

❖ Neurotransmitters that are implicated in neuroadaptations

❖ Conditioned Reinforcement and Incentive Salience

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Neurobiological mechanisms of the withdrawal/negative affect stage

The withdrawal/negative affect stage consists of chronic irritability, emotional pain, malaise,dysphoria, alexithymia, states of stress, and loss of motivation for natural rewards.

❖ Elevations in reward thresholds

❖ Neurochemical changes/ within-system neuroadaptations:

• Decreases in dopaminergic and serotonergic transmission

• Increases in μ opioid receptor, and

• Decrease in GABAergic and increases in NMDA glutamatergic transmission in the NucleusAccumbens.

❖ Decreases in reward function and increases in stress function

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Neurobiological mechanisms of the withdrawal/negative affect stage

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Neurobiological mechanisms of thepreoccupation/anticipation stage❖ Pre-frontal Cortex

❖ Go-system and Stop-system

❖ Insular functions

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Management of SubstanceAbuse/DependencePharmacological Treatment of Substance Abuse:

OPIOID

❖Methadone (Dolophine®, Methadose®),

❖ Buprenorphine (Suboxone®, Subutex®, Probuphine® , Sublocade™), and

❖ Naltrexone (Vivitrol®)

NICOTINE

❖ Nicotine replacement therapies in the form of patch, spray, gum, and lozenges.

❖ Prescription medications for nicotine addiction: Bupropion (Zyban®) and Varenicline (Chantix®)

ALCOHOL

❖ Naltrexone

❖ Acamprosate (Campral®)

❖ Disulfiram (Antabuse®)

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Management of SubstanceAbuse/DependenceDetoxification:

❖ Evaluation

❖ Stabilization and medication to coping with withdrawal symptoms by antidepressants, Clonidine

Self help groups

❖Meet others with same problem

❖Motivation

Rehabilitation programs

❖ Therapeutic communities

❖ Recovery housing

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Management of SubstanceAbuse/Dependence

Behavioural Therapy:

❖ Done by a psychologist, psychiatrist or a licensed alcohol and drug counselor

❖Behavioral therapies help patients:

• modify their attitudes and behaviors related to drug use

• increase healthy life skills

• persist with other forms of treatment, such as medication

Behavioral treatment includes:

• cognitive-behavioral therapy

• multidimensional family therapy

• motivational interviewing

• motivational incentives

Cognitive Behavioural Therapy for Relapse Prevention

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Neurobiology of Yoga in De-AddictionEmotion Regulation:

❖ Prefrontal Cortex activation (Creswell et al. 2007; Hölzel et al. 2008 , 2011a; Kang et al. 2013)

❖ Deactivation of Amygdala (Desbordes et al. 2012 ; Hölzel et al. 2010 ).

❖ Part of prefrontal cortex, in addition to the anterior cingulate cortex, the orbitofrontal cortex and parts of the insula termed as insula can be strengthened. (Creswell et al. 2007 ; Esch and Stefano 2010)

❖ Enhanced connectivity between the PFC and limbic areas (Desbordes et al. 2012 ; Hölzel et al. 2011a)

❖ Yoga meditation has been associated with greater functional connectivity between the DMN (Brewer et al., 2011; Hasenkamp et al. 2012)

Attention Regulation:

❖The prefrontal or orbitofrontal brain activates relevant dopaminergic midbrain structures and enhance the overall PFC-limbic (dopaminergic) connectivity (Esch and Stefano 2010; Kang et al. 2013)

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Neurobiology of Yoga in De-AddictionNeuromolecular Aspects of Meditation:

❖ Lower values are found for plasma NE in meditators (Infante et al. 2001).

❖ Plasma Serotonin levels are raised (Bujatti, M., and P. Riederer. 1976.)

❖Meditation increases peripheral melatonin levels and reduces cortisol levels (Liou et al. 2010, Solerberg et al 2004)

❖ Yoga increases beta-endorphine levels (Yadav et al. 2012)

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Yoga for De-addictionSl

No.

Title of the study

(Author name, Journal &

Year)

Population and

Sample size

Intervention Control

Intervention

Outcome

Measures

Results

1. Mindfulness Meditation

and Substance Use in an

Incarcerated Population

(Bowen, Sarah, et

al. Psychology of addictive

behaviors. 2006)

Users of various

substances

N=305

Vipasana

Meditation for 10

days

N=63

treatment-as-

usual aftercare

(TAU)

n=242

• The Daily Drinking

Questionnaire & the

Daily Drug-Taking

Questionnaire

• The Short Inventory of

Problems

• Drinking-Related Locus

of Control scale

• The White Bear

Suppression Inventory &

the Brief Symptom

Inventory

Collected at 0, post-

intervention, 3 & 6

months post-release.

At 3 months, compared to Controls,

Meditation reduced (p<0.05) alcohol

[ES 0.6], cocaine [ES 0.35] and

marijuana [ES 0.5] use, and alcohol-

related consequences [ES 0.35], and

improved psychiatric symptoms,

drinking-related locus of control and

optimism; the changes were related

to the VM participation;

2. A randomized trial of yoga

for stress and substance use

among people living with

HIV in re-entry

(Alexandra S, et al. Journal

of Substance Abuse

Treatment, 2018)

Subjects having

HIV with

substance use

disorder

N=73

Hatha yoga

practice for 12-

session, weekly

90-minute

N=37

Treatment as

usual

N=36

• Perceived Stress Scale

(PSS)

• The Timeline Follow-

back (TLFB)

• Measured at baseline,

4th session, 8th session,

post yoga, 1st, 2nd and

3rd month follow-up

At 3-months, yoga participants

reported less stress than

participants in treatment as usual [F

(1,59) = 9.24, p < .05]. Yoga

participants reported less substance

use than participants in treatment

as usual at 1-month, 2-months, and

3-months [p < .001]. 25

Sl

No.

Title of the study

(Author name, Journal &

Year)

Population

and Sample

size

Intervention Control

Intervention

Outcome

Measures

Results

3. Antidepressant efficacy and

hormonal effects of

Sudarshana Kriya

Yoga (SKY) in alcohol

dependent individuals

(A. Vedamurthachar et al.

Journal of Affective

Disorders, 2006)

Inpatients of

alcohol

dependence

N=60

SKY therapy for 2

weeks

N=30

Continued

inpatient care

only

n=30

• Beck Depression Inventory

(BDI)

• Morning plasma cortisol,

ACTH and prolactin

Measured before and at the

end of two weeks.

In both groups reductions in BDI

scores occurred but significantly

more so in SKY group. Likewise, in

both groups

plasma cortisol as well as ACTH fell

after two weeks but significantly

more so in SKY group. Reduction in

BDI scores correlated with that in

cortisol in SKY but not in control

group.

4. Yoga as an adjunct

treatment for alcohol

dependence: A pilot study

(Mats Hallgren, et al.,

Complementary Therapies in

Medicine, 2014)

Alcohol

dependent

patients

N=18

Treatment as

usual + Yoga for

10 weeks

Only treatment

as usual

• Alcohol consumption (timeline

follow-back method, DSM-IV

criteria for alcohol dependence,

and the Short Alcohol

Dependence Data

questionnaire)

• Affective symptoms (the

Hospital Anxiety and

Depression Scale)

• Quality of life (Sheehan

Disability Scale) and

• Stress (the Perceived Stress

Scale and saliva cortisol)

Assessments were taken at

baseline and sixth month

followup.

Alcohol consumption reduced more

in the treatment as usual plus yoga

group (from 6.32 to 3.36 drinks per

day) compared to the treatment as

usual only group (from 3.42 to 3.08

drinks per day).

26

Sl No. Title of the study

(Author name, Journal &

Year)

Population

and Sample

size

Intervention Control

Intervention

Outcome

Measures

Results

5. The effect of a yoga

intervention on alcohol and

drug abuse risk in veteran and

civilian women with

posttraumatic stress disorder.

(Reddy S, Dick AM, Gerber

MR, Mitchell K. J Altern

Complement Med. 2014)

Women with

PTSD having

alcohol and

drug abuse

behaviours

N=38

Kripalu-based

Hatha yoga for 12

sessions of 75

minutes each

N=20

Waitlist control

N=18

• Alcohol use disorder

identification test (AUDIT)

• Drug Use Disorders Identification

Test (DUDIT)

Administered at baseline, post

intervention and 1st month follow-

up

The mean AUDIT and DUDIT scores

decreased in the yoga group; in the

control group, mean AUDIT

score increased while mean DUDIT

score remained stable. Most yoga

group participants reported a

reduction in symptoms and improved

symptom management.

6. Yoga as an Adjunctive

Intervention to Medication-

Assisted Treatment with

Buprenorphine+Naloxone

(Lander, Laura, et al. Journal

of addiction research &

therapy, 2018)

Opioid addicts

N=26

Adjunctive yoga

intervention

while remaining

in treatment as

usual for 12

weeks

N=13

Treatment as

usual

N=13

• Perceived stress scale

• Opioid craving scale

• Sleep scale from the medical

outcomes study

• Beck Anxiety Inventory (BAI)

Done at baseline, 45 days and 90

days

The treatment by follow-up time

interaction effect was significant for

perceived stress (p=0.026) indicating

that the yoga intervention had a larger

effect than TAU. Changes in perceived

stress decreased significantly over time

in both the yoga intervention group

and the TAU matched control group.

7. Mindfulness-based therapy

modulates default-mode

network connectivity in

patients with opioid

dependence

(Fahmy R, Wasfi M, et al.

European

Neuropsychopharmacology.

2019)

opiate

dependent

patients

N=32

Mindfulness

based therapy for

4 weeks

N=16

Treatment as

usual

N=16

• Resting-state functional MRI

used to investigate distinct

(anterior vs. posterior) DMN

subsystems

Within the anterior DMN, decreased

right inferior frontal cortical

connectivity was detected in patients

who received MBT compared to TAU.

In addition, within the MBT-group

decreased right superior frontal cortex

connectivity was detected after

treatment. Inferior frontal cortex

function was significantly associated

with mindfulness measures.27

Sl

No.

Title of the study

(Author name, Journal &

Year)

Population

and Sample

size

Intervention Control

Intervention

Outcome

Measures

Results

8. Effectiveness of yogic

breathing intervention on

quality of life of opioid

dependent users

(Dhawan A, et al., Int J Yoga.

2015)

Opioid

Dependent

individuals

N=84

12 hours

Sudarshan Kriya

Yoga for 3 days

along with long

term standard

pharmacothera

py

N=55

Standard

treatment

alone

N=29

• World Health Organization

QOL-brief scale

• Urine drug screening

Assessment done at baseline,

3rd and 6th month

Overtime within study group, all

four QOL domain scores were

significantly higher at 6 months.

Between group comparison

showed significant increase in

physical (P < 0.05); psychological

(P < 0.001) and environment

domains (P < 0.001) for study

group while control group showed

significant changes in social

relationship domain only. Urine

screening results were negative for

study group indicating no drug use

at 6 months.

9. 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

(Agarwal RP, et al. J Altern

Complement Med, 2015)

Users of

crack

cocaine

who is also

having HIV

N=24

Yoga/Meditatio

n for 1hour

twice a week

for two months

N=12

No

intervention.

Contacted only

for assessments

N=12

• Short Form-36

• Perceived Stress Scale [PSS]

• Impact of Events Scale

[IES])

• Salivary cortisol and

• dehydroepiandrosterone

sulfate (DHEA-S)

YM participants showed modest

improvements on QOL. The PSS

total score and the IES intrusion

score improved significantly 2

months after the intervention, but

cortisol and DHEA-S did not

change.

28

Sl

No.

Title of the study

(Author name, Journal &

Year)

Population

and Sample

size

Intervention Control

Intervention

Outcome

Measures

Results

10. Mindfulness training for

smoking cessation: Results

from a randomized

controlled trial

(Judson A. Brewer, Sarah

Mallik, et al. Drug and

Alcohol Dependence, 2011)

Nicotine-

dependent

adults

N=88

Mindfulness

training for

weekly twice for

four weeks

N=41

Freedom from

smoking (FFS)

treatment

N=47

• Self-reported smoking via the

timeline follow back (TLFB)

method

• Exhaled carbon monoxide

(CO) measurement

Assessed weekly twice, end of 4

weeks and follow-up at week 17

Compared to those randomized to

the FFS intervention, individuals who

received MT showed a greater rate of

reduction in cigarette use during

treatment and maintained these

gains during follow-up (F = 11.11, p =

.001). They also exhibited a trend

toward greater point prevalence

abstinence rate at the end of

treatment (36% vs. 15%, p = .063),

which was significant at the 17-week

follow-up (31% vs. 6%, p = .012).

11. Yoga as a complementary

treatment for smoking

cessation in women. (Bock

BC, et al,. Journal of

Women's Health. 2012)

Women with

smoking

addiction

N=55

Group-based CBT

for smoking

cessation + yoga

program (yoga)

for twice a week

for 8 weeks

N=32

CBT for smoking

cessation plus a

group-based

wellness

program

N=23

• 7-day point prevalence

abstinence (7PPA), verified by

saliva cotinine level less than

57 nmol/L (15 ng/mL) done

after the treatment

• Smoking history and nicotine

dependence (FTND),

measures of anxiety (STAIT),

depressive symptoms (CESD-

10), short-form Health

Survey: SF-36

Assessed at 3rd and 6th week

follow-up

Women in the yoga group had a

greater 7-day point-prevalence

abstinence rate than controls (odds

ratio [OR], 4.56; 95% CI, 1.1–18.6).

Abstinence remained higher among

yoga participants through the 6th

month assessment (OR, 1.54; 95% CI,

0.34–6.92), but not statistically

significant.

Women participating in the yoga

program also showed reduced

anxiety and improvements in

perceived health and well-being

when compared with controls.29

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❖ Desbordes, G., L.T. Negi, T.W.W. Pace, B.A. Wallace, C.L. Raison, and E.L. Schwartz. 2012. Effects of mindful-attention and compassion meditation training on amygdala response to emotional stimuli in an ordinary, non-meditative state. Frontiers in Human Neuroscience 6: 292.

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THANK YOU!

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