Neurofeedback Training for Opiate Addiction: Improvement of Mental Health and Craving

Substance use disorder is characterized by physiological dependence accompanied by the withdrawal syndrome upon abstinence from the drug, psychological dependence with craving, a pathological motivational state that leads to active drug-seeking behavior, and tolerance, expressed in the escalation of the dose needed to achieve a desired euphoric state (Sadock and Sadock 2008). It is a chronic, relapsing mental disease that results from the prolonged effects of drugs on the brain (Dackis and O’Brien 2001; Volkow et al. 2003, 2004). Opiate dependence refers to a cluster of substance use disorders with physiological, behavioral, and cognitive symptoms, which, taken together, indicate repeated and continuing use of opiate drugs despite significant problems related to such use (Sadock and Sadock 2008). Drug and opiate substance dependence can take control of the brain and behavior by activating and reinforcing behavioral patterns that are excessively directed to compulsive drug use (Di Chiara 1999; Gerdeman et al. 2003).

The effects of pharmacological and behavioral treatment for substance dependence have been criticized as being limited (Fagan 1994). While major resources have been employed to study and treat substance dependence, there has been minimal improvement in success rates of treatment and the relapse rate is typically over 70 % (Higgins et al. 1995). Gossop et al. (2002) reported 60 % of heroin addicts relapsed 1 year following substance dependence treatment. Effective treatment for substance dependence will always require a combined biological, physiological and psychological approach. Few treatment programs address the neurological and physiological issues of substance dependence (Sokhadze et al. 2008).

In recent years, the psychological and neurophysiologic dimensions of substance dependence have attracted more scientific attention (National Institute on Drug Abuse 2000). Volkow et al. (1988) were the first to use positron emission tomography (PET) to study the effects of cocaine on the human brain. This study has played a central role in ascertaining the interactions between the brain, drug and behavior in humans. Studies have shown that some symptoms of substance and opiate dependence such as craving, impulsiveness, and psychological abnormalities, are connected to pathological neurophysiology (Kaufman 2000; Dackis and O’Brien 2001; Hubbard and Martin 2001; Volkow et al. 2003, 2004; Ardila et al. 1991). Quantitative electroencephalography (QEEG) as a kind of brain mapping technique can characterize some of these abnormalities (Newton et al. 2003). The spontaneous EEG activity of substance and opiate dependence patients is characterized by alterations mainly within the alpha, theta and beta bands (Alper et al. 1998; Sokhadze et al. 2008), which may be the result of prolonged substance use itself (Ardila et al. 1991; Marchesi et al. 1992; O’Mahony and Doherty 1996).

The limitations of pharmacotherapy and behavioral therapy, combined with knowledge from studies on nerophysiological abnormalities in substance dependence, underline the need for alternative and/or complementary therapies for these disorders, with long lasting effects and minimal side effects (Hubbard and Martin 2001). Neurofeedback appears to be a promising alternative due to effects such as reduced drug seeking symptoms, improved psychological and neurophysiological variables and longer periods of abstinence that have been reported in the literature after neurofeedback treatment (Peniston and Kulkosky 1989; Masterpasqua and Healey 2003; Scott et al. 2005v Sokhadze et al. 2008).

Neurofeedback as a branch of biofeedback technology, is an operant conditioning technique used to reinforce or inhibit specific forms of EEG activity (Scott et al. 2005v Kaiser and Othmer 2000). It is a therapeutic method designed to train the mind and body to act in a more optimal way in order to improve emotional, cognitive, physical, and behavioral experiences (Demos 2005). Today, based on the research in neuropathology, we can use this method to turn abnormal rhythms and frequencies (based on QEEG) into normal (or relatively normal) rhythms and frequencies, and following that, turn abnormal psychological states into normal ones (Gunkelman and Johnstone 2005). Neurofeedback has been used as a therapeutic method to treat different types of disorders, for example attention deficit hyperactivity disorder (Kropotov et al. 2007; Strehl et al. 2006; Rossiter 2004; Fuchs et al. 2003), epilepsy (Kotchoubey et al. 2001), depression (Putman 2001), anxiety and affective disorders (Hammond 2005; Vanathy et al. 1998), fibromyalgia (Muller et al. 2001), and obsessive compulsive disorder (Hammond 2003), and also to enhance attention and memory performance in healthy subjects (Wilson et al. 2006; Hanslmayr et al. 2005; Egner et al. 2002; Vernon et al. 2003). This technique also has been used as a therapeutic method for substance or alcohol dependent patients, and results have corroborated the efficiency of neurofeedback treatment on negative neuropsychological consequences of these disorders (Sokhadze et al. 2008; Scott et al. 2005; Frederick et al. 2005; Burkett et al. 2004; Masterpasqua and Healey 2003; Lawrence 2002; Kaiser et al. 1999; Peniston and Saxby 1995).

Alpha training was the first neurofeedback (EEG biofeedback) protocol that was employed in substance and alcohol dependence disorders. Research by Passini et al. (1977) has shown the effects of alpha neurofeedback training in reducing anxiety and improving aspects of personality in drug dependence patients. Goldberg and Hillier (1979) reported that their alpha conditioning program reduced drug use and increased self-control in 4 patients addicted to opioids. Afterward the treatment of addictive disorders by EEG biofeedback or neurofeedback was popularized by the work of Eugene Peniston (Peniston and Kulkosky 1989, 1991) and became popularly known as the Peniston Protocol. In Peniston’s (1989) neurofeedback study, ten alcoholic patients underwent approximately 40 alpha-theta brain wave training sessions. These patients had all failed previous hospital residential treatment programs. Eight of them remained generally abstinent at least three years after neurofeedback treatment (Peniston and Kulkosky 1989). This protocol also resulted in a decrease of 13 on the millon clinical multiaxial inventory scales (MCMI), including anxiety, whereas traditional treatment produced decreases of only two points on these scales (Peniston and Kulkosky 1991).

In 1992, Fahrion, Walters, Coyne and Allen replicated these results in a controlled case study. They also reported a decrease in stress-related, blood based beta endorphins and in substance craving in patients. In researches completed by Bodehnamer and Callaway (2004) and Burkett et al. (2004) on crack-cocaine abusers improvements in mental state, craving and neurological functions have been reported. In another experimental study, participants who received neurofeedback treatment (alpha-theta training) showed significant improvement in their mood and in their Minnesota multiphase personality inventory-2 (MMPI-2) scales (Raymond et al. 2005). Follow-up studies showed the constancy of treatment outcomes in alcohol or drug addicted clients who completed an alpha-theta neurofeedback training program (Kelley 1997; Bodenhamer-Davis and BeBeus 1995; Trudeau 2000).

In a more recent study Scott et al. (2005) gave mixed substance dependence patients feedback on their brain’s electrical activity in conjunction with conventional treatment. They reported that their treatment doubled the recovery rate for drug dependence. In addition to improving the success rate for recovery from use of drugs, the study documented significant improvements in the ability of the experimental group to focus their thinking and information processing. Moreover, the experimental subjects exhibited significant improvement in some relevant measures of psychological functioning. After only 45 days of treatment, nearly one-third of the control group had dropped out of treatment prematurely and left the residential facility, compared to only 6 % for the experimental group. Even thought all of the works presented thus far were conducted on adults, Trudeau (2005) also suggested that neurofeedback could be effective for helping adolescents with substance use disorders.

Despite all these promising results, neurofeedback treatment has not yet beenaccepted as a standard therapy for substance dependence disorders because there are only a few studies in this field, and most of them have been conducted on alcoholic patients. In this study we examined the effectiveness of the neurofeedback method combined with pharmacotherapy in opiate dependence. We believe this is the first study to examine the effects of neurofeedback treatment in addition to Methadone or Buprenorphine maintenance treatment (MMT/BMT) on improvement of comorbid abnormalities in opiate dependent patients. A comprehensive assessment was carried out on general psychological health and substance craving. This study aimed at answering (a) if neurofeedback treatment leads to an improvement in mental health and craving for opiates and (b) if the two experimental and control groups differ in mental health and craving variables. This paper compares results from both groups.