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Yoga and substance use disorders: A narrative review
Accepted Manuscript Title: Yoga and substance use disorders: A Narrative Review Author: Siddharth Sarkar Mohit Varshney PII: DOI: Reference:
S1876-2018(16)30386-0 http://dx.doi.org/doi:10.1016/j.ajp.2016.10.021 AJP 983
To appear in: Received date: Revised date: Accepted date:
28-8-2016 22-10-2016 29-10-2016
Please cite this article as: Sarkar, Siddharth, Varshney, Mohit, Yoga and substance use disorders: A Narrative Review.Asian Journal of Psychiatry http://dx.doi.org/10.1016/j.ajp.2016.10.021 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
Yoga and substance use disorders: A Narrative Review
1. Dr Siddharth Sarkar, MD 2. Dr Mohit Varshney, MD
Affiliation: Department of Psychiatry and NDDTC, AIIMS, New Delhi
Highlights
Yoga has been found to have beneficial effect as an adjunctive treatment modality, to supplement other medically oriented treatment, for Substance Use Disorders Yoga can help individuals during both short term (Detoxification) and long term management of Substance Use; by various mechanisms It is highly likely that it will be accepted by the patient community as an add on treatment There are specific issues that should be kept in mind while evaluating the available literature on Yoga and substance use Expansion of database is needed to use Yoga as an “Evidence based treatment”
Abstract Yoga has been utilized for promotion of health and alleviating distress. It has also been used as a therapeutic measure in the field of mental health, including substance use disorders. This narrative review discusses the literature pertaining to use of yoga in the treatment of substance use disorders. The evidence base especially with regards to randomized trials is presented. The possible mechanisms how yoga might be helpful in the treatment of substance use disorders is explored. Subsequently, implications of yoga in clinical practice are elaborated, followed by examination of the issues in interpretation of the literature of published yoga related studies. Keywords: alcohol, breathing exercises, drug, substance, Yoga
Introduction: Yoga has been conceptualized as a science of consciousness, which deals with the evolution of personality of the individual.(Nagendra, 2008) It has been described by Patanjali to comprise of several aspects including yamas (restraints), niyamas (observance of rules), asana(posture), pranayama (control or breath), pratyahara (withdrawal of senses), dharana (concentration), dhyana(meditation), and Samadhi (self-realization).(Khanna and Greeson, 2013) Yoga has been in practiced in the Indian sub-continent for centuries and has been promoted as a way of life, as well as means for improving the overall health of the individual. Yoga has been practiced in various forms. Hatha yoga, i.e. the yoga of attaining mental and physical purity remains the most commonly practiced forms of yoga, though other forms of yoga like raj yoga (yoga of awakening the consciousness), jnana yoga (yoga of knowledge and wisdom) and karma yoga (yoga of action) do exist. Hatha yoga has been popularized in various forms and styles, including that of Iyengar yoga, Bikram yoga, Kundalini yoga etc. It generally refers to a set of physical exercises (known as asanas or postures), and sequences of asanas, designed to align your skin, muscles, and bone(Khanna and Greeson, 2013; Shaffer et al., 1997). Yoga has been utilized for promotion of health and alleviating distress .(Chong et al., 2011) Yoga as a therapeutic measure has been used in the field of mental health.(Posadzki et al., 2010) Not only yoga has been used in the treatment of stress, depression, anxiety disorders, and childhood disorders,(Cramer et al., 2013; da Silva et al., 2009; Galantino et al., 2008; Shaibani AA, et al, n.d.; Singh RB, et al., n.d.) it has also been utilized in the treatment of substance use disorders.(Khanna and Greeson, 2013; Posadzki et al., 2014) Substance use disorders are among the common disorders across the world, and are associated with considerable social costs.(Rehm et al., 2006, 2009) The course of substance use disorders is often protracted with relapses and remissions. High rates of discontinuation of treatment have propelled the search for newer therapies. Yoga, as a form of alternate and complementary therapy holds promise of providing a yet another treatment option in the armamentarium for
therapeutic options for substance use disorders. Hence, this narrative review aims to discuss yoga as therapeutic option for substance use disorders. The review discusses the evidence available for yoga as an option for substance use disorders, followed by mechanisms purported to describe its action, followed by the limitations in the literature and the future directions for the field. The review is based upon the English language literature published in peer reviewed journals and indexed in PubMed database conducted in July 2016. The keywords for the search included „yoga‟ with terms implying various substance use disorders. A scoping review of Google Scholar and Medknow search engines was also done to identify additional studies of interest. The review does not include other related meditative practices like mindfulness based stress reduction until they specifically identified themselves as a form of yoga. A quantitative synthesis or meta-analysis was not performed as a part of this review. Efficacy of yoga in substance use disorders The clinical studies that have evaluated the efficacy of substance use disorders have been highlighted in table 1. Shaffer et al(1997) assessed the compared the efficacy of add-on Hatha yoga to group psychodynamic therapy in a group of patients on methadone maintenance. The investigators randomized 61 patients on methadone maintenance into Hatha Yoga and group psychodynamic therapy interventions. The authors found that both the interventions resulted in improved outcomes for the patient in terms of drug use and criminal behaviour. There were no significant differences between the groups in terms of the efficacy measures. Raina et al(2001) studied the effect of Yoga sessions of 40 minutes duration conducted 6 days a week for 8 weeks with physical exercise. The investigators randomized 50 alcohol dependent men into yoga and physical exercise groups. Improvement or recovery at 8 weeks was noted in 80% of the subjects in the yoga group and 48% subjects in the control group, suggesting that yoga performed better than physical exercise among patients with alcohol dependence. McIver et al(2004) studied the effect of yoga intervention that occurred once a week for 60 minutes over a period of 5 weeks among 20 residents of a therapeutic community. The investigators attempted to discern the change in motivation to quit tobacco over the course of the yoga based intervention. The investigators found that the motivation to quit tobacco had increased significantly over the course of the period of yoga intervention. Kochupillai et al(2005) attempted to ascertain the efficacy the Sudarshan Kriya Yoga over the course of 6 months of follow up. They had included 82 smokers who completed the 6 days Art of Living workshop which taught Sudarshan Kriya and suggested the participants to continue this form of yoga at their homes. At 6 months, they were able to follow up 34 participants, of whom 17 were abstinent from tobacco. With an intention to treat design, the success rate of the intervention was reported as 21% (17 out of 82 participants).
Sharma and Corbin,(2006) randomized 21 participants into yoga group or printed reading material control. The participants in the yoga group had flexibility of schedule of the yoga intervention. The investigators found that mean total self-control in the yoga group increased during the 6 month period of intervention, while it decreased in the control group. Vedamurthachar et al(2006) studied a group of 60 alcohol dependent individuals who were received either Sudarshan Kriya Yoga or treatment as usual over two weeks. In both the groups, the depressive symptoms had deceased, but significantly so in the Sudarshan Kriya Yoga group. Similarly, plasma cortisol levels decreased significantly more in the Yoga group than controls. In a study conducted by Sareen et al(2007) among patients with chronic pancreatitis, 90% of whom were „alcoholic‟ at some point in their lives, the investigators compared yoga to treatment as usual controls. Among the 60 patients randomized equally to both the groups, the intervention group received thrice a week yoga sessions lasting about 1 hour for 12 weeks. The study found that at 12 weeks intervention, mood profile and stress scores significantly decreased in the yoga group as compared to treatment as usual. Khalsa et al,(2008) studied the effect of Kundalini based residential yoga treatment in a group of eight patients with a variety of substance use disorders (alcohol, opiates and barbiturates). The subjects were members in a residential treatment facility who underwent Kundalini yoga over a period of 90 days. Compared to baseline values, the intervention group showed improvement in self-reported symptoms and problem severity, as well as the quality of recovery, though perceived stress did not change over the course of yoga intervention. Elibero et al(2011) conducted a randomized controlled trial examining the effect of hatha yoga, physical exercise and non-activity control on cue-elicited craving to smoke. The study included 76 daily smokers, who completed measures of craving and mood before, immediately after and 20 minutes after the intervention. The investigators found that both physical exercise and hatha yoga groups had significant decrease in craving as compared to non-activity controls. Marefat et al(2011) studied 24 individuals, 12 in experimental group who received 60 minutes thrice weekly yoga sessions for 5 weeks, and 12 in wait list control group. As compared to controls, the individuals in the experimental group had significant decrease in state anxiety and depression over the course of the follow-up period. Rawat et al,(2011) studied 20 heavy smokers divided into two groups – one who received intervention in the form of yoga along with Sudarshan Kriya and the other which received only yoga. The investigators found that at the end of 6 weeks, the group with Sudarshan Kriya and yoga performed better than that only yoga in terms of reducing the habit of smoking and quitting tobacco product. Bock et al(2012) randomized fifty-five women smokers enrolled in a group-based cognitive behaviour program. The women were randomized into add-on 60 minute Vinyasa yoga program conducted twice weekly for 8 weeks (the sessions being conducted by certified yoga
therapists) or a wellness contact control. The study found that the intervention group had higher rates of smoking cessation at 8 weeks (Odds ratio [OR] 4.19, 95% confidence intervals [CI] 1.2 to 15.1), though the cessation rates were not different at 3 and 6 months follow-up. Shahab et al,(2013) randomized 96 individuals to either yogic breathing exercises which was practiced for 10 minutes, or a video control condition of breathing exercise video. The participants in the yogic breathing exercise were asked to practice the breathing to control the craving. The yogic breathing exercise performed better than control condition in controlling the craving to smoke in the immediate post-intervention period, but the effect did not last in the 24-hours follow-up period. The authors note that the adherence with the breathing exercise regimen was low in the 24 hours following the intervention. Zhuang et al, (2013) studied Chinese women undergoing residential treatment program for heroin dependence in a hospital setting. Eight one women were randomized either into an intervention group comprising of yoga six days a week for 6 months, or a control condition comprising of routine care at the hospital. The investigators found that yoga group showed a significant improvement in mood status and quality of life over time compared to the control group. Devi et al,(2014) randomized a group of patients with substance use disorder into a yoga group which received daily yoga sessions for 4 weeks, and a control group. The yoga intervention improved the depressive symptoms significantly in the intervention group over the 4 weeks. The intervention also resulted in improvement in the quality of life domains of physical, psychological and social health. Hallgren et al(2014) randomized 18 alcohol dependent individuals into weekly group yoga for 10 weeks or treatment as usual groups. The investigators found that end of the intervention, alcohol consumption reduced to a greater extent in the treatment as usual plus yoga group compared to the treatment as usual only group, though the differences were not significant. Dhawan et al(2015) studied the effect of Sudarshan Kriya Yoga among patient who were already receiving buprenorphine for treatment of opiate dependence. Eighty four subjects were randomized into Sudarshan Kriya group and treatment-as-usual control. The participants were assessed at 3 and 6 months follow-up. Compared to treatment-as-usual group, patients in the intervention group had better outcomes in the physical, psychological and environmental quality of life. The literature above suggests that yoga has been used as a treatment modality for a variety of substance use disorders including tobacco, alcohol, opiates and others. It has typically been used as an adjunctive treatment modality, supplementing other medically oriented treatment approaches for substance use disorders. It can be used in outpatient as well as residential setting, with the caveat that the frequency of yoga sessions would be expected to be lower in the outpatient setting. The studies above do suggest that yoga confers some beneficial effect in helping patients to quit substance taking behaviour and maintain abstinence.
Mechanisms of how Yoga might be helpful in substance use disorders Yoga might be helpful for individuals with substance use disorders at two time periods. One is at the time of cessation of substance use (i.e. during detoxification), and the other for preventing relapse to substance taking behaviour. Essentially, during both the time periods, yoga helps the individual by reducing the amount of stress. Detoxification, or the immediate period of cessation of substance use is usually a stressful period for the individual. Discontinuation of certain substances like alcohol, benzodiazepines and opiates is associated with sympathetic discharge. This is accompanied by increased heart rate and blood pressure. Yogic breathing exercises may help to reduce the heart rate and blood pressure.(Bharshankar et al., 2015) Hence, it might be helpful for individuals who have been undergoing detoxification from substances of use. The other manner in which yoga might be helpful in individuals with substance use disorders involves influence on the affective processing and the level of arousal of individuals with substance use disorders. Relapses to substance taking behaviour occur when the individual is exposed to cues or an unpleasant affect. Regular practice of yoga reduces the stress leves and helps a person to deal more effectively with negative emotions. It reduces baseline stress levels as has been demonstrated by lowering of the galvanic skin responses in patients with chronic alcohol dependence who have been practicing yoga.(Kumar, 2011) Cortisol is a stress hormone which is released when the individual is exposed to stress for longer duration of time. Reduction of stress among patients in alcohol dependence has been demonstrated in the form of decrease in the levels of cortisol and ACTH in patients who have been performing yoga.(Vedamurthachar et al., 2006) Yoga can also help to alleviate negative mood states,(Li and Goldsmith, 2012; Uebelacker et al., 2010) which are often precipitants of relapse to substance taking behaviour.(Zywiak et al., 2006) Behaviorally, yoga conducted in pro-social groups may provide additional social supports for participants of yoga program to keep off substances. The various possible mechanisms by which yoga may be helpful in patients with substance use disorders is schematically summarized in figure 1.
Implications for clinical practice for substance use disorders Several factors make yoga a promising approach for treatment of substance use disorders, especially in South Asia. Yoga has been demonstrated to be helpful in improving outcomes of patients with substance use disorders as mentioned before. Hence, offering yoga services, either in group format or individually may further improve the rates of cessation of substance use and abstinence among patients who want to leave substances of abuse. Being an indigenous form of health promotion measure, it is likely to be more acceptable for the Indian patients. Cognizant with the fact of popularization of yoga in the recent past, it is likely that yoga would be quite easily accepted by the patient community elsewhere too, provided efficacy is clearly documented. When would be a good time to initiate yoga intervention?
Typically yoga intervention would be beneficial for patients when they are out of the acute withdrawal stage. Patients are likely to attend to the yoga sessions and practice its use when they have been medically stabilized and are in frame of mind to think about enhancing their lifestyle and use measures to reduce their stress. Who should deliver the yoga intervention? Ideally yoga should be taught by practitioners trained in yoga. Abstinent substance users who have themselves learnt yoga may be helpful in delivering this intervention to others. Group or individual format It would be quite up to the therapeutic services how they would like to provide yoga sessions. Well defined timings where a group of patients congregate may be helpful in improving ties among the patients and would help them learn from each other. At the same time, individuals may not have synchronous schedules or have additional free time, and hence in such situation, sessions may be held upon individual basis as well. Residential or outpatient? In places where patients with substance use disorder are housed for longer durations of time, a residential format may be preferred where yoga sessions are coupled with the daily itinerary. In services which cater to patients primarily on outpatient basis, the yoga sessions may be incorporated in a group format scheduled on specific days and times, which can be attended by the interested patients. Add-on treatment? Yoga interventions for patients with substance use disorders would be considered as a complementary and alternative treatment. This suggests that such intervention would best be coupled with other treatment modalities like medications or psychotherapy. For how long? Yoga interventions should be promoted at least for a few weeks time in which the participant familiarizes himself/herself with the yoga recommended for him/her, and practices it. This would give an opportunity to teach the yoga measure accurately. Longer duration continuation of sessions might be helpful to motivate the individual to maintain abstinence. Participants would be encouraged to continue the sessions at home for longer durations of time, and reminders for continuation may help them to avoid stopping of home-based practice of yoga. Issues in deciphering the literature Efficacy of yoga as a treatment modality has been often difficult to be reliably ascertained. This has been primarily because several issues that may confound the findings or make direct comparisons with other treatment options difficult.
The first issue pertains to what comprises yoga, or how to define yoga. Conceptual variations do exist in definition of yoga. Though asanas and breathing exercises are just a form of yoga, other forms do exist which are more encompassing and attempt to define yoga more broadly. Some experts mention yoga as a way of life, and hence, differences may arise in the manner yoga is conceptualized. The definition of the „construct‟ of yoga is important from the perspective of the conduct of a study, but may pose challenges in certain situations. A related issue remains of differentiating yoga from other closely related constructs like mindfulness based stress reduction. Hence, it may be prudent to assess how yoga has been conceptualized. Secondly, different experts would teach different forms of yoga. Also, there would be variations in the duration of the yoga sessions, differences in expertise of the instructor, differences in the interest and inclination of the participants towards yoga, and the regularity/ frequency of the yoga practice (including the at-home practices). Sometimes, these pertinent details are not clearly forthcoming from the published report.(Elwy et al., 2014) The third issue relates to finding a suitable control condition. An active control intervention is better suited to discern the effect of yoga vis-a-vis another active treatment modality or an active attention control. This is because yoga interventions typically involve substantial time involvement of the instructor. So, it would be needed to be seen at least whether the yoga intervention performs better than the active attention. Another issue pertains to using yoga as a stand-alone intervention or as an addendum to other standard intervention. Yoga promises as a health promotion intervention with minimal adverse effects. Yet, efficacy is yet to be proven as a stand-alone measure for substance use disorders. When given with a standard treatment, the incremental efficacy of the yoga intervention needs to be considered carefully. Thus, there are several issues that need to be considered while interpreting the information available from studies reporting the effect of yoga in a clinical population.
What the future holds for Yoga in the field of substance use disorders Though some evidence has accrued for the role of yoga in the treatment of substance use disorders over the last couple of decades, further work needs to be done to firmly advocate the role of this modality in the treatment of substance use disorders. Firstly, expansion of evidence base needs to be attempted. Adequately powered randomized controlled trials with substantial follow-up duration would help in bolstering the case for yoga to be espoused on a larger scale. This needs to work in tandem on attempting to find the means through which it works, especially given the progress in neuroimaging modalities for finding the effect of yoga of the brain.(Hazari and Sarkar, 2014) Secondly, capacity building in the form of training yoga personnel and offering them linkages with de-addiction treatment services may help to disseminate the effects of yoga on a larger scale. Thirdly, funding opportunities of yoga based interventions may be increased and it may be brought under insurance cover so that larger numbers of individuals are able to derive benefits from such an intervention. With these
measures, it can be speculated that yoga may have a larger role in the treatment of patients with substance use disorders. References: Bharshankar, J.R., Mandape, A.D., Phatak, M.S., Bharshankar, R.N., 2015. Autonomic Functions In Raja-yoga Meditators. Indian J Physiol Pharmacol 59, 396–401. Bock, B.C., Fava, J.L., Gaskins, R., Morrow, K.M., Williams, D.M., Jennings, E., Becker, B.M., Tremont, G., Marcus, B.H., 2012. Yoga as a complementary treatment for smoking cessation in women. J. Womens Health 2002 21, 240–248. doi:10.1089/jwh.2011.2963 Chong, C.S.M., Tsunaka, M., Tsang, H.W.H., Chan, E.P., Cheung, W.M., 2011. Effects of yoga on stress management in healthy adults: A systematic review. Altern. Ther. Health Med. 17, 32–38. Cramer, H., Lauche, R., Langhorst, J., Dobos, G., 2013. Yoga for depression: a systematic review and meta-analysis. Depress. Anxiety 30, 1068–1083. doi:10.1002/da.22166 da Silva, T.L., Ravindran, L.N., Ravindran, A.V., 2009. Yoga in the treatment of mood and anxiety disorders: A review. Asian J. Psychiatry 2, 6–16. doi:10.1016/j.ajp.2008.12.002 Devi, N.J., Singh, T.B., Subramanya, P., 2014. Effect of yoga on depression and quality of life in drug abusers. Int. J. Ayurveda Pharma Res. 2, 61–66. Dhawan, A., Chopra, A., Jain, R., Yadav, D., Vedamurthachar, null, 2015. Effectiveness of yogic breathing intervention on quality of life of opioid dependent users. Int. J. Yoga 8, 144–147. doi:10.4103/0973-6131.154075 Elibero, A., Janse Van Rensburg, K., Drobes, D.J., 2011. Acute effects of aerobic exercise and Hatha yoga on craving to smoke. Nicotine Tob. Res. Off. J. Soc. Res. Nicotine Tob. 13, 1140–1148. doi:10.1093/ntr/ntr163 Elwy, A.R., Groessl, E.J., Eisen, S.V., Riley, K.E., Maiya, M., Lee, J.P., Sarkin, A., Park, C.L., 2014. A systematic scoping review of yoga intervention components and study quality. Am. J. Prev. Med. 47, 220–232. Galantino, M.L., Galbavy, R., Quinn, L., 2008. Therapeutic effects of yoga for children: a systematic review of the literature. Pediatr. Phys. Ther. Off. Publ. Sect. Pediatr. Am. Phys. Ther. Assoc. 20, 66–80. doi:10.1097/PEP.0b013e31815f1208 Hallgren, M., Romberg, K., Bakshi, A.-S., Andréasson, S., 2014. Yoga as an adjunct treatment for alcohol dependence: a pilot study. Complement. Ther. Med. 22, 441– 445. doi:10.1016/j.ctim.2014.03.003 Hazari, N., Sarkar, S., 2014. A review of yoga and meditation neuroimaging studies in healthy subjects. Altern. Complement. Ther. 20, 16–26. Khalsa, S.B.S., Khalsa, G.S., Khalsa, H.K., Khalsa, M.K., 2008. Evaluation of a residential Kundalini yoga lifestyle pilot program for addiction in India. J. Ethn. Subst. Abuse. 7, 67–79. doi:10.1080/15332640802081968 Khanna, S., Greeson, J.M., 2013. A narrative review of yoga and mindfulness as complementary therapies for addiction. Complement. Ther. Med. 21, 244–252. doi:10.1016/j.ctim.2013.01.008 Kochupillai, V., Kumar, P., Singh, D., Aggarwal, D., Bhardwaj, N., Bhutani, M., Das, S.N., 2005. Effect of rhythmic breathing (Sudarshan Kriya and Pranayam) on immune functions and tobacco addiction. Ann. N. Y. Acad. Sci. 1056, 242–252. doi:10.1196/annals.1352.039 Kumar, L.R., 2011. Role of Anuloma Viloma pranayama in reducing stress in Chronic Alcoholics. Pak J Physiol 7, 11–16.
Li, A.W., Goldsmith, C.-A.W., 2012. The effects of yoga on anxiety and stress. Altern. Med. Rev. J. Clin. Ther. 17, 21–35. Marefat, M., Peymanzad, H., Alikhajeh, Y., 2011. The study of the effects of yoga exercises on addicts‟ depression and anxiety in rehabilitation period. Procedia-Soc. Behav. Sci. 30, 1494–1498. McIver, S., O‟Halloran, P., McGartland, M., 2004. The impact of Hatha yoga on smoking behavior. Altern. Ther. Health Med. 10, 22–23. Nagendra, H.R., 2008. Defining yoga. Int. J. Yoga 1, 43–44. doi:10.4103/0973-6131.43540 Posadzki, P., Choi, J., Lee, M.S., Ernst, E., 2014. Yoga for addictions: a systematic review of randomised clinical trials. Focus Altern. Complement. Ther. 19, 1–8. Posadzki, P., Parekh, S., Glass, N., 2010. Yoga and qigong in the psychological prevention of mental health disorders: a conceptual synthesis. Chin. J. Integr. Med. 16, 80–86. doi:10.1007/s11655-009-9002-2 Raina, N., Chakraborty, P.K., Basit, M.A., Samarth, S.N., Singh, H., 2001. Evaluation of yoga therapy in alcohol dependence syndrome. Indian J. Psychiatry 43, 171–174. Rawat, H., Anuradha, V., Rawat, L., Rawat, R., 2011. How Sudharshan Kriya helps to reduce the habit of smoking and motivate to quit smoking. Int J Pharm Sci Rev Res 6, 27–28. Rehm, J., Mathers, C., Popova, S., Thavorncharoensap, M., Teerawattananon, Y., Patra, J., 2009. Global burden of disease and injury and economic cost attributable to alcohol use and alcohol-use disorders. Lancet Lond. Engl. 373, 2223–2233. doi:10.1016/S0140-6736(09)60746-7 Rehm, J., Taylor, B., Room, R., 2006. Global burden of disease from alcohol, illicit drugs and tobacco. Drug Alcohol Rev. 25, 503–513. doi:10.1080/09595230600944453 Sareen, S., Kumari, V., Gajebasia, K.-S., Gajebasia, N.-K., 2007. Yoga: a tool for improving the quality of life in chronic pancreatitis. World J. Gastroenterol. 13, 391–397. Shaffer, H.J., LaSalvia, T.A., Stein, J.P., 1997. Comparing Hatha yoga with dynamic group psychotherapy for enhancing methadone maintenance treatment: a randomized clinical trial. Altern. Ther. Health Med. 3, 57–66. Shahab, L., Sarkar, B.K., West, R., 2013. The acute effects of yogic breathing exercises on craving and withdrawal symptoms in abstaining smokers. Psychopharmacology (Berl.) 225, 875–882. doi:10.1007/s00213-012-2876-9 Shaibani AA, et al, n.d. Stress, peace and the heart. World Heart J 2015; 7:265-274. [WWW Document]. URL http://search.proquest.com/openview/5a34a20b5f431e721d4c781575100e9c/1?pqorigsite=gscholar&cbl=2034815 (accessed 10.21.16). Sharma, M., Corbin, D.E., 2006. A preliminary study of the effects of an innovative social cognitive theory driven yoga-based behavioral intervention on smoking cessation. Calif J Health Promot 4, 63–76. Singh RB, et al., n.d. Can Circadian Restriction of Feeding Modulate Autonomic Nervous System Dysfunction and Cardiometabolic Risk? WHJ 2015; 7: 197-208 [WWW Document]. URL https://www.novapublishers.com/catalog/product_info.php?products_id=54071 (accessed 10.21.16). Uebelacker, L.A., Epstein-Lubow, G., Gaudiano, B.A., Tremont, G., Battle, C.L., Miller, I.W., 2010. Hatha yoga for depression: critical review of the evidence for efficacy, plausible mechanisms of action, and directions for future research. J. Psychiatr. Pract. 16, 22–33. doi:10.1097/01.pra.0000367775.88388.96 Vedamurthachar, A., Janakiramaiah, N., Hegde, J.M., Shetty, T.K., Subbakrishna, D.K., Sureshbabu, S.V., Gangadhar, B.N., 2006. Antidepressant efficacy and hormonal
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Table 1: Studies which have evaluated the efficacy of yoga in substance use disorders Author, year
Type of Yoga study description RCT Yoga, 75 minutes for 22 weeks
Substance(s) Findings
Raina et al, 2001
RCT
Alcohol
McIver et al, 2004
Single Group
Kochupillai et al, 2005
Single Group
Yoga, 40 minutes, 6 days a week for 8 weeks Yoga, 60 minutes, once a week for 5 weeks Sudarshan Kriya Yoga
Sharma and Corbin, 2006
RCT
Yoga scheduled at convenience of participants
Tobacco
Vedamurthachar RCT et al, 2006
Sudarshan Kriya Yoga hourly for 2 weeks Yoga, 1 hour sessions thrice a week for 12 weeks Kundalini yoga residential program of 90 days Hatha yoga for 30 minutes on 1 occassion
Alcohol
Shaffer et al, 1997
Methadone maintenance
Tobacco in a residential therapeutic community Tobacco
No difference between add-on Yoga and dynamic group psychotherapy. Both treatments reduced drug use and criminal activities Yoga group improved more significantly as compared to physical exercise at 8 weeks Improvement in the motivation for change stage. Post test motivation scores better than pre-test ones. Seventeen of the 34 tobacco users followed up at 6 months were abstinent Yoga group had significant increase in mean total self control for quitting as compared to controls who were just given reading materials Depressive symptoms decrease more significantly in the Sudarshan Kriya Yoga group
Alcohol†
Improvement in mood profile and stress symptoms in yoga group as compared to controls
Mixed (alcohol, opiates, barbiturates)
Improvement in psychological symptoms over the course of yoga intervention
Tobacco
Hatha yoga and physical exercise had significant decrease in craving to smoke compared to controls Yoga resulted in significant reduction in anxiety and depression as compared to wait-list control Additional Sudarshan Kriya with yoga helps better to quit smoking
Sareen et al, 2007
RCT
Khalsa et al, 2008
Single Group
Elibero et al, 2011
RCT
Marefat et al, 2011
RCT
Yoga, three times a week for 5 weeks
Clients in therapeutic community
Rawat et al, 2011
Control led design
Yoga compared to Yoga with Sudarshan
Tobacco
Bock et al, 2012
RCT
Shahab et al, 2013
RCT
Kriya Vinyasa yoga twice weekly of 60 minutes duration for 8 weeks, as an add-on to CBT Yogic breathing exercises for 10 minutes
Tobacco
Tobacco
Yoga add-on group had greater abstinence rates at 8 weeks, but difference was not significant at 6 months follow-up
In the immediate intervention period, yogic breathing exercises group had lower craving as compared to video control group Zhuang et al, RCT Yoga, 6 days a Heroin Mood state and quality of life 2013 week for 6 improved in the intervention months group as compared to control Devi et al, 2014 RCT Yoga for 70 Multiple Improvement in the yoga group minutes daily (Heroin, in terms of depressive for 4 weeks alcohol, symptoms and quality of life spasmaprox (physical, psychological and yvon) social domains) Hallgren et al, RCT Weekly group Alcohol Non-significant difference in 2014 session for 10 add-on yoga group in terms of weeks alcohol consumption Dhawan et al, RCT Sudarshan Opiate Intervention group had better 2015 Kriya Yoga outcomes in physical, 3hours (12 psychological and hour program) environmental quality of life than controls. (CBT Cognitive Behaviour Therapy, RCT Randomized Controlled Trial, †Conducted among patients with chronic pancreatitis majority of whom were alcoholics)
Figure 1: Yoga in Substance Use Disorder Management
S1876-2018(16)30386-0 http://dx.doi.org/doi:10.1016/j.ajp.2016.10.021 AJP 983
To appear in: Received date: Revised date: Accepted date:
28-8-2016 22-10-2016 29-10-2016
Please cite this article as: Sarkar, Siddharth, Varshney, Mohit, Yoga and substance use disorders: A Narrative Review.Asian Journal of Psychiatry http://dx.doi.org/10.1016/j.ajp.2016.10.021 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
Yoga and substance use disorders: A Narrative Review
1. Dr Siddharth Sarkar, MD 2. Dr Mohit Varshney, MD
Affiliation: Department of Psychiatry and NDDTC, AIIMS, New Delhi
Highlights
Yoga has been found to have beneficial effect as an adjunctive treatment modality, to supplement other medically oriented treatment, for Substance Use Disorders Yoga can help individuals during both short term (Detoxification) and long term management of Substance Use; by various mechanisms It is highly likely that it will be accepted by the patient community as an add on treatment There are specific issues that should be kept in mind while evaluating the available literature on Yoga and substance use Expansion of database is needed to use Yoga as an “Evidence based treatment”
Abstract Yoga has been utilized for promotion of health and alleviating distress. It has also been used as a therapeutic measure in the field of mental health, including substance use disorders. This narrative review discusses the literature pertaining to use of yoga in the treatment of substance use disorders. The evidence base especially with regards to randomized trials is presented. The possible mechanisms how yoga might be helpful in the treatment of substance use disorders is explored. Subsequently, implications of yoga in clinical practice are elaborated, followed by examination of the issues in interpretation of the literature of published yoga related studies. Keywords: alcohol, breathing exercises, drug, substance, Yoga
Introduction: Yoga has been conceptualized as a science of consciousness, which deals with the evolution of personality of the individual.(Nagendra, 2008) It has been described by Patanjali to comprise of several aspects including yamas (restraints), niyamas (observance of rules), asana(posture), pranayama (control or breath), pratyahara (withdrawal of senses), dharana (concentration), dhyana(meditation), and Samadhi (self-realization).(Khanna and Greeson, 2013) Yoga has been in practiced in the Indian sub-continent for centuries and has been promoted as a way of life, as well as means for improving the overall health of the individual. Yoga has been practiced in various forms. Hatha yoga, i.e. the yoga of attaining mental and physical purity remains the most commonly practiced forms of yoga, though other forms of yoga like raj yoga (yoga of awakening the consciousness), jnana yoga (yoga of knowledge and wisdom) and karma yoga (yoga of action) do exist. Hatha yoga has been popularized in various forms and styles, including that of Iyengar yoga, Bikram yoga, Kundalini yoga etc. It generally refers to a set of physical exercises (known as asanas or postures), and sequences of asanas, designed to align your skin, muscles, and bone(Khanna and Greeson, 2013; Shaffer et al., 1997). Yoga has been utilized for promotion of health and alleviating distress .(Chong et al., 2011) Yoga as a therapeutic measure has been used in the field of mental health.(Posadzki et al., 2010) Not only yoga has been used in the treatment of stress, depression, anxiety disorders, and childhood disorders,(Cramer et al., 2013; da Silva et al., 2009; Galantino et al., 2008; Shaibani AA, et al, n.d.; Singh RB, et al., n.d.) it has also been utilized in the treatment of substance use disorders.(Khanna and Greeson, 2013; Posadzki et al., 2014) Substance use disorders are among the common disorders across the world, and are associated with considerable social costs.(Rehm et al., 2006, 2009) The course of substance use disorders is often protracted with relapses and remissions. High rates of discontinuation of treatment have propelled the search for newer therapies. Yoga, as a form of alternate and complementary therapy holds promise of providing a yet another treatment option in the armamentarium for
therapeutic options for substance use disorders. Hence, this narrative review aims to discuss yoga as therapeutic option for substance use disorders. The review discusses the evidence available for yoga as an option for substance use disorders, followed by mechanisms purported to describe its action, followed by the limitations in the literature and the future directions for the field. The review is based upon the English language literature published in peer reviewed journals and indexed in PubMed database conducted in July 2016. The keywords for the search included „yoga‟ with terms implying various substance use disorders. A scoping review of Google Scholar and Medknow search engines was also done to identify additional studies of interest. The review does not include other related meditative practices like mindfulness based stress reduction until they specifically identified themselves as a form of yoga. A quantitative synthesis or meta-analysis was not performed as a part of this review. Efficacy of yoga in substance use disorders The clinical studies that have evaluated the efficacy of substance use disorders have been highlighted in table 1. Shaffer et al(1997) assessed the compared the efficacy of add-on Hatha yoga to group psychodynamic therapy in a group of patients on methadone maintenance. The investigators randomized 61 patients on methadone maintenance into Hatha Yoga and group psychodynamic therapy interventions. The authors found that both the interventions resulted in improved outcomes for the patient in terms of drug use and criminal behaviour. There were no significant differences between the groups in terms of the efficacy measures. Raina et al(2001) studied the effect of Yoga sessions of 40 minutes duration conducted 6 days a week for 8 weeks with physical exercise. The investigators randomized 50 alcohol dependent men into yoga and physical exercise groups. Improvement or recovery at 8 weeks was noted in 80% of the subjects in the yoga group and 48% subjects in the control group, suggesting that yoga performed better than physical exercise among patients with alcohol dependence. McIver et al(2004) studied the effect of yoga intervention that occurred once a week for 60 minutes over a period of 5 weeks among 20 residents of a therapeutic community. The investigators attempted to discern the change in motivation to quit tobacco over the course of the yoga based intervention. The investigators found that the motivation to quit tobacco had increased significantly over the course of the period of yoga intervention. Kochupillai et al(2005) attempted to ascertain the efficacy the Sudarshan Kriya Yoga over the course of 6 months of follow up. They had included 82 smokers who completed the 6 days Art of Living workshop which taught Sudarshan Kriya and suggested the participants to continue this form of yoga at their homes. At 6 months, they were able to follow up 34 participants, of whom 17 were abstinent from tobacco. With an intention to treat design, the success rate of the intervention was reported as 21% (17 out of 82 participants).
Sharma and Corbin,(2006) randomized 21 participants into yoga group or printed reading material control. The participants in the yoga group had flexibility of schedule of the yoga intervention. The investigators found that mean total self-control in the yoga group increased during the 6 month period of intervention, while it decreased in the control group. Vedamurthachar et al(2006) studied a group of 60 alcohol dependent individuals who were received either Sudarshan Kriya Yoga or treatment as usual over two weeks. In both the groups, the depressive symptoms had deceased, but significantly so in the Sudarshan Kriya Yoga group. Similarly, plasma cortisol levels decreased significantly more in the Yoga group than controls. In a study conducted by Sareen et al(2007) among patients with chronic pancreatitis, 90% of whom were „alcoholic‟ at some point in their lives, the investigators compared yoga to treatment as usual controls. Among the 60 patients randomized equally to both the groups, the intervention group received thrice a week yoga sessions lasting about 1 hour for 12 weeks. The study found that at 12 weeks intervention, mood profile and stress scores significantly decreased in the yoga group as compared to treatment as usual. Khalsa et al,(2008) studied the effect of Kundalini based residential yoga treatment in a group of eight patients with a variety of substance use disorders (alcohol, opiates and barbiturates). The subjects were members in a residential treatment facility who underwent Kundalini yoga over a period of 90 days. Compared to baseline values, the intervention group showed improvement in self-reported symptoms and problem severity, as well as the quality of recovery, though perceived stress did not change over the course of yoga intervention. Elibero et al(2011) conducted a randomized controlled trial examining the effect of hatha yoga, physical exercise and non-activity control on cue-elicited craving to smoke. The study included 76 daily smokers, who completed measures of craving and mood before, immediately after and 20 minutes after the intervention. The investigators found that both physical exercise and hatha yoga groups had significant decrease in craving as compared to non-activity controls. Marefat et al(2011) studied 24 individuals, 12 in experimental group who received 60 minutes thrice weekly yoga sessions for 5 weeks, and 12 in wait list control group. As compared to controls, the individuals in the experimental group had significant decrease in state anxiety and depression over the course of the follow-up period. Rawat et al,(2011) studied 20 heavy smokers divided into two groups – one who received intervention in the form of yoga along with Sudarshan Kriya and the other which received only yoga. The investigators found that at the end of 6 weeks, the group with Sudarshan Kriya and yoga performed better than that only yoga in terms of reducing the habit of smoking and quitting tobacco product. Bock et al(2012) randomized fifty-five women smokers enrolled in a group-based cognitive behaviour program. The women were randomized into add-on 60 minute Vinyasa yoga program conducted twice weekly for 8 weeks (the sessions being conducted by certified yoga
therapists) or a wellness contact control. The study found that the intervention group had higher rates of smoking cessation at 8 weeks (Odds ratio [OR] 4.19, 95% confidence intervals [CI] 1.2 to 15.1), though the cessation rates were not different at 3 and 6 months follow-up. Shahab et al,(2013) randomized 96 individuals to either yogic breathing exercises which was practiced for 10 minutes, or a video control condition of breathing exercise video. The participants in the yogic breathing exercise were asked to practice the breathing to control the craving. The yogic breathing exercise performed better than control condition in controlling the craving to smoke in the immediate post-intervention period, but the effect did not last in the 24-hours follow-up period. The authors note that the adherence with the breathing exercise regimen was low in the 24 hours following the intervention. Zhuang et al, (2013) studied Chinese women undergoing residential treatment program for heroin dependence in a hospital setting. Eight one women were randomized either into an intervention group comprising of yoga six days a week for 6 months, or a control condition comprising of routine care at the hospital. The investigators found that yoga group showed a significant improvement in mood status and quality of life over time compared to the control group. Devi et al,(2014) randomized a group of patients with substance use disorder into a yoga group which received daily yoga sessions for 4 weeks, and a control group. The yoga intervention improved the depressive symptoms significantly in the intervention group over the 4 weeks. The intervention also resulted in improvement in the quality of life domains of physical, psychological and social health. Hallgren et al(2014) randomized 18 alcohol dependent individuals into weekly group yoga for 10 weeks or treatment as usual groups. The investigators found that end of the intervention, alcohol consumption reduced to a greater extent in the treatment as usual plus yoga group compared to the treatment as usual only group, though the differences were not significant. Dhawan et al(2015) studied the effect of Sudarshan Kriya Yoga among patient who were already receiving buprenorphine for treatment of opiate dependence. Eighty four subjects were randomized into Sudarshan Kriya group and treatment-as-usual control. The participants were assessed at 3 and 6 months follow-up. Compared to treatment-as-usual group, patients in the intervention group had better outcomes in the physical, psychological and environmental quality of life. The literature above suggests that yoga has been used as a treatment modality for a variety of substance use disorders including tobacco, alcohol, opiates and others. It has typically been used as an adjunctive treatment modality, supplementing other medically oriented treatment approaches for substance use disorders. It can be used in outpatient as well as residential setting, with the caveat that the frequency of yoga sessions would be expected to be lower in the outpatient setting. The studies above do suggest that yoga confers some beneficial effect in helping patients to quit substance taking behaviour and maintain abstinence.
Mechanisms of how Yoga might be helpful in substance use disorders Yoga might be helpful for individuals with substance use disorders at two time periods. One is at the time of cessation of substance use (i.e. during detoxification), and the other for preventing relapse to substance taking behaviour. Essentially, during both the time periods, yoga helps the individual by reducing the amount of stress. Detoxification, or the immediate period of cessation of substance use is usually a stressful period for the individual. Discontinuation of certain substances like alcohol, benzodiazepines and opiates is associated with sympathetic discharge. This is accompanied by increased heart rate and blood pressure. Yogic breathing exercises may help to reduce the heart rate and blood pressure.(Bharshankar et al., 2015) Hence, it might be helpful for individuals who have been undergoing detoxification from substances of use. The other manner in which yoga might be helpful in individuals with substance use disorders involves influence on the affective processing and the level of arousal of individuals with substance use disorders. Relapses to substance taking behaviour occur when the individual is exposed to cues or an unpleasant affect. Regular practice of yoga reduces the stress leves and helps a person to deal more effectively with negative emotions. It reduces baseline stress levels as has been demonstrated by lowering of the galvanic skin responses in patients with chronic alcohol dependence who have been practicing yoga.(Kumar, 2011) Cortisol is a stress hormone which is released when the individual is exposed to stress for longer duration of time. Reduction of stress among patients in alcohol dependence has been demonstrated in the form of decrease in the levels of cortisol and ACTH in patients who have been performing yoga.(Vedamurthachar et al., 2006) Yoga can also help to alleviate negative mood states,(Li and Goldsmith, 2012; Uebelacker et al., 2010) which are often precipitants of relapse to substance taking behaviour.(Zywiak et al., 2006) Behaviorally, yoga conducted in pro-social groups may provide additional social supports for participants of yoga program to keep off substances. The various possible mechanisms by which yoga may be helpful in patients with substance use disorders is schematically summarized in figure 1.
Implications for clinical practice for substance use disorders Several factors make yoga a promising approach for treatment of substance use disorders, especially in South Asia. Yoga has been demonstrated to be helpful in improving outcomes of patients with substance use disorders as mentioned before. Hence, offering yoga services, either in group format or individually may further improve the rates of cessation of substance use and abstinence among patients who want to leave substances of abuse. Being an indigenous form of health promotion measure, it is likely to be more acceptable for the Indian patients. Cognizant with the fact of popularization of yoga in the recent past, it is likely that yoga would be quite easily accepted by the patient community elsewhere too, provided efficacy is clearly documented. When would be a good time to initiate yoga intervention?
Typically yoga intervention would be beneficial for patients when they are out of the acute withdrawal stage. Patients are likely to attend to the yoga sessions and practice its use when they have been medically stabilized and are in frame of mind to think about enhancing their lifestyle and use measures to reduce their stress. Who should deliver the yoga intervention? Ideally yoga should be taught by practitioners trained in yoga. Abstinent substance users who have themselves learnt yoga may be helpful in delivering this intervention to others. Group or individual format It would be quite up to the therapeutic services how they would like to provide yoga sessions. Well defined timings where a group of patients congregate may be helpful in improving ties among the patients and would help them learn from each other. At the same time, individuals may not have synchronous schedules or have additional free time, and hence in such situation, sessions may be held upon individual basis as well. Residential or outpatient? In places where patients with substance use disorder are housed for longer durations of time, a residential format may be preferred where yoga sessions are coupled with the daily itinerary. In services which cater to patients primarily on outpatient basis, the yoga sessions may be incorporated in a group format scheduled on specific days and times, which can be attended by the interested patients. Add-on treatment? Yoga interventions for patients with substance use disorders would be considered as a complementary and alternative treatment. This suggests that such intervention would best be coupled with other treatment modalities like medications or psychotherapy. For how long? Yoga interventions should be promoted at least for a few weeks time in which the participant familiarizes himself/herself with the yoga recommended for him/her, and practices it. This would give an opportunity to teach the yoga measure accurately. Longer duration continuation of sessions might be helpful to motivate the individual to maintain abstinence. Participants would be encouraged to continue the sessions at home for longer durations of time, and reminders for continuation may help them to avoid stopping of home-based practice of yoga. Issues in deciphering the literature Efficacy of yoga as a treatment modality has been often difficult to be reliably ascertained. This has been primarily because several issues that may confound the findings or make direct comparisons with other treatment options difficult.
The first issue pertains to what comprises yoga, or how to define yoga. Conceptual variations do exist in definition of yoga. Though asanas and breathing exercises are just a form of yoga, other forms do exist which are more encompassing and attempt to define yoga more broadly. Some experts mention yoga as a way of life, and hence, differences may arise in the manner yoga is conceptualized. The definition of the „construct‟ of yoga is important from the perspective of the conduct of a study, but may pose challenges in certain situations. A related issue remains of differentiating yoga from other closely related constructs like mindfulness based stress reduction. Hence, it may be prudent to assess how yoga has been conceptualized. Secondly, different experts would teach different forms of yoga. Also, there would be variations in the duration of the yoga sessions, differences in expertise of the instructor, differences in the interest and inclination of the participants towards yoga, and the regularity/ frequency of the yoga practice (including the at-home practices). Sometimes, these pertinent details are not clearly forthcoming from the published report.(Elwy et al., 2014) The third issue relates to finding a suitable control condition. An active control intervention is better suited to discern the effect of yoga vis-a-vis another active treatment modality or an active attention control. This is because yoga interventions typically involve substantial time involvement of the instructor. So, it would be needed to be seen at least whether the yoga intervention performs better than the active attention. Another issue pertains to using yoga as a stand-alone intervention or as an addendum to other standard intervention. Yoga promises as a health promotion intervention with minimal adverse effects. Yet, efficacy is yet to be proven as a stand-alone measure for substance use disorders. When given with a standard treatment, the incremental efficacy of the yoga intervention needs to be considered carefully. Thus, there are several issues that need to be considered while interpreting the information available from studies reporting the effect of yoga in a clinical population.
What the future holds for Yoga in the field of substance use disorders Though some evidence has accrued for the role of yoga in the treatment of substance use disorders over the last couple of decades, further work needs to be done to firmly advocate the role of this modality in the treatment of substance use disorders. Firstly, expansion of evidence base needs to be attempted. Adequately powered randomized controlled trials with substantial follow-up duration would help in bolstering the case for yoga to be espoused on a larger scale. This needs to work in tandem on attempting to find the means through which it works, especially given the progress in neuroimaging modalities for finding the effect of yoga of the brain.(Hazari and Sarkar, 2014) Secondly, capacity building in the form of training yoga personnel and offering them linkages with de-addiction treatment services may help to disseminate the effects of yoga on a larger scale. Thirdly, funding opportunities of yoga based interventions may be increased and it may be brought under insurance cover so that larger numbers of individuals are able to derive benefits from such an intervention. With these
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Table 1: Studies which have evaluated the efficacy of yoga in substance use disorders Author, year
Type of Yoga study description RCT Yoga, 75 minutes for 22 weeks
Substance(s) Findings
Raina et al, 2001
RCT
Alcohol
McIver et al, 2004
Single Group
Kochupillai et al, 2005
Single Group
Yoga, 40 minutes, 6 days a week for 8 weeks Yoga, 60 minutes, once a week for 5 weeks Sudarshan Kriya Yoga
Sharma and Corbin, 2006
RCT
Yoga scheduled at convenience of participants
Tobacco
Vedamurthachar RCT et al, 2006
Sudarshan Kriya Yoga hourly for 2 weeks Yoga, 1 hour sessions thrice a week for 12 weeks Kundalini yoga residential program of 90 days Hatha yoga for 30 minutes on 1 occassion
Alcohol
Shaffer et al, 1997
Methadone maintenance
Tobacco in a residential therapeutic community Tobacco
No difference between add-on Yoga and dynamic group psychotherapy. Both treatments reduced drug use and criminal activities Yoga group improved more significantly as compared to physical exercise at 8 weeks Improvement in the motivation for change stage. Post test motivation scores better than pre-test ones. Seventeen of the 34 tobacco users followed up at 6 months were abstinent Yoga group had significant increase in mean total self control for quitting as compared to controls who were just given reading materials Depressive symptoms decrease more significantly in the Sudarshan Kriya Yoga group
Alcohol†
Improvement in mood profile and stress symptoms in yoga group as compared to controls
Mixed (alcohol, opiates, barbiturates)
Improvement in psychological symptoms over the course of yoga intervention
Tobacco
Hatha yoga and physical exercise had significant decrease in craving to smoke compared to controls Yoga resulted in significant reduction in anxiety and depression as compared to wait-list control Additional Sudarshan Kriya with yoga helps better to quit smoking
Sareen et al, 2007
RCT
Khalsa et al, 2008
Single Group
Elibero et al, 2011
RCT
Marefat et al, 2011
RCT
Yoga, three times a week for 5 weeks
Clients in therapeutic community
Rawat et al, 2011
Control led design
Yoga compared to Yoga with Sudarshan
Tobacco
Bock et al, 2012
RCT
Shahab et al, 2013
RCT
Kriya Vinyasa yoga twice weekly of 60 minutes duration for 8 weeks, as an add-on to CBT Yogic breathing exercises for 10 minutes
Tobacco
Tobacco
Yoga add-on group had greater abstinence rates at 8 weeks, but difference was not significant at 6 months follow-up
In the immediate intervention period, yogic breathing exercises group had lower craving as compared to video control group Zhuang et al, RCT Yoga, 6 days a Heroin Mood state and quality of life 2013 week for 6 improved in the intervention months group as compared to control Devi et al, 2014 RCT Yoga for 70 Multiple Improvement in the yoga group minutes daily (Heroin, in terms of depressive for 4 weeks alcohol, symptoms and quality of life spasmaprox (physical, psychological and yvon) social domains) Hallgren et al, RCT Weekly group Alcohol Non-significant difference in 2014 session for 10 add-on yoga group in terms of weeks alcohol consumption Dhawan et al, RCT Sudarshan Opiate Intervention group had better 2015 Kriya Yoga outcomes in physical, 3hours (12 psychological and hour program) environmental quality of life than controls. (CBT Cognitive Behaviour Therapy, RCT Randomized Controlled Trial, †Conducted among patients with chronic pancreatitis majority of whom were alcoholics)
Figure 1: Yoga in Substance Use Disorder Management