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Complementary and alternative medicine for addiction: an
overview of systematic reviews
Pawel Posadzki, Mohamed MK Khalil, Abdullah MN AlBedah, Olena Zhabenko,
Josip Car
Abstract
Background Complementary and alternative medicine (CAM) is popular among individuals with a variety of
addictions.
Objective To critically evaluate the evidence from systematic reviews (SRs) of the effectiveness of CAM for addictions.
Methods Ten electronic databases were searched from their inception to January 2015. Systematic reviews (SRs) of
any type of CAM with any type of addiction-related outcome were considered eligible. The Oxman criteria for assessing
the methodological quality of the included SRs were used.
Results Twenty-seven SRs met the inclusion criteria. Most of them were of high methodological quality (mean=4.66,
SD=5.20). Twelve SRs arrived at equivocal conclusions (of these, seven were of high quality), four drew positive
conclusions (three of which were of high quality), and 11 arrived at negative conclusions (of which six were of high
quality). A wide variety of addictions were examined, including alcohol, amphetamine, cannabis, cocaine,
methamphetamine, opiates (heroin, morphine, opium), tobacco and various (unspecified) drugs. A diversity of CAM
modalities was also used such as acupuncture (and related techniques), herbal medicine, hypnotherapy, meditative/
mindfulness techniques, music therapy, spirituality and yoga.
Conclusion A large number of SRs exist in the area of addiction. The evidence from SRs examining the effectiveness
of various CAM interventions for myriad addictions is highly ambiguous or negative.
Keywords
Addictions complementary and alternative medicine effectiveness systematic reviews
Introduction
Addiction can be defined as a primary, chronic dis-
ease of brain reward, motivation, memory and
related circuitry.
1
According to the Diagnostic and
Statistical Manual of Mental Disorders, 5th edn
(DSM–5), addiction from alcohol, caffeine, illicit or
prescription drugs or tobacco constitutes a sub-
stance-related disorder.
2
The World Health Organi-
zation (WHO) has estimated that in 2010, between
153 and 300 million people worldwide aged 15–
64 years had used an illicit substance (excluding
alcohol) at least once in the preceding year.
3
The
burden of addiction for individuals and societies
around the globe is significant.
Complementary and alternative medicine (CAM)
can be defined as ‘diagnosis, treatment and/or pre-
vention which complements mainstream medicine
by contributing to a common whole, satisfying a
demand not met by orthodoxy, or diversifying the
conceptual framework of medicine’.
4
The National
Center for Complementary and Integrative Health
(NCCIH) (formerly National Center for Complemen-
tary and Alternative Medicine, NCCAM)
operationally divides CAM into five categories: alter-
native medical systems, mind–body interventions,
1
REVIEW
Focus on Alternative and
Complementary Therapies
Volume () 2016
©2016 Royal Pharmaceutical Society
DOI 10.1111/fct.12255
ISSN 1465-3753
biologically based therapies, manipulative and body-
based methods and energy therapies.
5
The prevalence of CAM use among patients with
addiction/substance use disorders is high, ranging
from 34%
6
to 45%.
7
There might be several expla-
nations for this high level of popularity; one reason
is that various CAM modalities are being promoted
as effective treatment strategies for addictions/sub-
stance use disorders. Some patients might also feel
that their needs are not being met by mainstream
psychiatry, and, as a result, seek alternatives. What-
ever the reasons are for this high level of popular-
ity, it is essential to identify the forms of CAM that
are safe and effective for addictions.
Many published RCTs have examined the effec-
tiveness of CAM modalities for various addictions,
and their results have been evaluated in systematic
reviews (SRs). Some of these SRs have arrived at
conflicting conclusions, which may be confusing.
To the best of our knowledge, no attempt has been
made to summarise and rigorously evaluate the evi-
dence from these SRs. The aim of this article is
therefore to review and critically appraise the data
from SRs of CAM for any type of addiction.
Methods
Data sources
The Google Scholar search engine and the follow-
ing nine databases were searched from their respec-
tive inceptions to January 2015: AMED, CINAHL,
The Cochrane Library, EMBASE, ISI Web of Knowl-
edge, ISI Web of Science, MEDLINE, PsycINFO, and
Scopus. A detailed search strategy for MEDLINE is
presented in Box 1. In addition to the electronic
searches, the reference lists of all identified papers
were reviewed for further potentially relevant SRs.
Study selection
The data screening and selection process were per-
formed by two independent reviewers (PP and
MMKK) and verified and validated by a third
reviewer (AMNA).
Eligibility
The present overview of SRs included all articles
evaluating the effects of CAM for any type of drug
addiction, including alcohol, amphetamine, canna-
bis, cocaine, methamphetamine, opiates (heroin,
morphine, opium), tobacco, or other unspecified
drugs. Papers published in English were considered
eligible. Systematic reviews were defined as articles
that include replicable eligibility criteria for primary
studies and a comprehensive and repeatable litera-
ture search method. Systematic reviews with over-
lapping RCTs, or updated SRs were also included.
Non-systematic reviews were excluded.
The following CAM modalities were considered
eligible: acupuncture (AT) and associated tech-
niques, Alexander Technique, Ayurvedic medicine,
aromatherapy, (Bach) flower remedies, biofeedback,
chiropractic, herbal medicine, homeopathy, hypno-
sis, massage, music therapy, meditation, mindful-
ness techniques, naturopathy, osteopathy, qigong,
spirituality/spiritual healing, tai chi, TCM and yoga.
Dietary supplements, physical exercises or psy-
chotherapeutic approaches were not considered a
part of CAM and were therefore excluded from the
analyses.
Any type of addiction-related outcome measures
were considered eligible.
Data extraction
Data extraction and quality assessments were per-
formed by the two selection reviewers (PP and MK)
independently of each other, using a predefined
data extraction form. The following information
was extracted from the included reviews: first
authors’ names and publication date, type of addic-
tion, total number of primary studies, quality of
primary studies (poor, moderate or high as deter-
mined by the present authors), whether meta-ana-
lysis had been conducted, quality of SR (Oxman
score
8
), overall result (quote), direction of conclu-
sion (judged by the present authors (positive, nega-
tive or equivocal), whether SR had mentioned
adverse effects (AEs) (yes or no), authors’ conflicts
of interest (declared or not mentioned), source of
funding (mentioned or not mentioned) and any
additional comments.
The direction of conclusions of each SR was eval-
uated in the following way: statements such as ‘no
Concept 1
(Alternative adj3 (heal$ or medic$ or remed$ or therap$
or treatment$)).ti,ab. OR (Complementary adj3 (heal$ or
medic$ or remed$ or therap$ or treatment$)).ti,ab. OR
(integrat$ adj3 (heal$ or medic$ or remed$ or therap$ or
treatment$)).ti,ab. OR CAM.ti,ab. OR exp Complementary
Therapies/
Concept 2
Substance-Related Disorders. sh OR addict*.ti,ab. OR over-
dos*.ti,ab. OR intoxicat*.ti,ab. OR abstin*.ti,ab. OR
abstain*.ti,ab. OR withdrawal*.ti,ab. OR abuse*.ti,ab. OR
use*.ti,ab. OR misuse.ti,ab. OR disorder*.ti,ab. OR depen-
den*.ti,ab.
Concept 3
review.ti
Box 1 Detailed search strategy for MEDLINE
2 Focus on Alternative and Complementary Therapies
2016 ()
evidence of benefit’ were categorised as ‘negative’,
or lack of effectiveness (); statements such as ‘a
significant effect of acupuncture was found in
smoking cessation rates’ were categorised as ‘posi-
tive’ (+) or existence of effectiveness; and state-
ments that were neither explicitly positive nor
clearly negative were categorised as ‘unclear’ (+/)
or existence of ambiguity. Any disagreements
regarding these categorisations were resolved by dis-
cussion between the authors.
Risk of bias assessment
The methodological quality of the included SRs was
independently evaluated by two reviewers using the
Oxman score.
8
This validated tool evaluates the qual-
ity of review articles in nine domains, including:
reporting of search strategy, comprehensiveness of
searches, repeatable eligibility criteria, avoidance of
selection bias, presence of a validity assessment tool,
use of the validity assessment tool, robustness of data
analysis, appropriateness of data analysis and sup-
portiveness of conclusions. Each question can be
scored as 1 (domain fulfilled), 0 (domain partially
fulfilled) or 1 (domain not fulfilled). The final score
ranges from 9 to 9. A result of 1 or below means the
review has extensive flaws; 2–3 indicates the pres-
ence of major flaws; 4–5 means minor flaws, and 6–9
indicates minimal or no flaws.
Data synthesis
The results are presented in a narrative fashion
using tables. Descriptive statistics were used to anal-
yse and synthesise the data. Sensitivity analyses
were conducted to explore the impact of the
methodological quality of each SR on the outcomes
of the review. Sensitivity analyses were conducted
according to the following criteria: (a) direction of
conclusion as a function of the quality of the SR
and primary trials; (b) quality of the SR (Oxman
score) as a function of addiction type; (c) quality of
the SR as a function of the quality of primary data;
and (d) direction of conclusion as a function of the
CAM modality.
Results
Study description
Our searches generated a total of 4035 records; 27
SRs met the inclusion criteria
9–35
(Figure 1). The
Records screened (n= 2054)
Duplicates removed (n= 1981)
Total number of hits for
electronic search (n= 4032) Additional records identified
through manual search (n= 3)
Excluded: not CAM
(n= 171)
Total number of articles
included (n= 27)
Full-text articles assessed
for eligibility (n= 198)
Excluded: not SR
(n= 1856)
Figure 1 Flow diagram for included studies. CAM, complementary and alternative medicine; SR, systematic review.
Review 3
Table 1 Systematic reviews of CAMs for addictions
First
author
(year)
Intervention(s) Type of
addiction
N*Quality
of RCTs
Meta-
analysis
Quality
of SR
(Oxman
score)
8
Overall result
(quote)
Direction of
conclusion
Mention
of adverse
effects
Conflict
of interest
Source
of funding
Comment
I: Alternative medical systems
Cheng
(2012)
13
AA, AP, AT,
EA, LA
Tobacco 20 Low to
moderate
Yes 7 ‘A significant effect of
acupoint stimulation
was found in smoking
cessation rates and cigarette
consumption at immediate,
3- and 6-month follow-ups’
(+) No n.m. n.m. Combined all types of
acupoint stimulation
thus significant heterogeneity
of the analyses; no funnel
plots provided
Cho
(2009)
15
AA, AEA, AT,
ALA, EA, LA,
Alcohol 11 Low Yes 9 ‘[T]he poor methodological
quality and the limited
number of the trials do
not allow any conclusion
about the efficacy of
acupuncture for
treatment of alcohol
dependence.’
(+/) Yes n.m. n.m. No statistically significant
differences between
AT and sham treatments
were found for
one of the POMs
D’Alberto
(2004)
16
AA Cocaine 6 Moderate No 4 ‘This review could not confirm
that AT was an effective
treatment for
cocaine abuse.’
() Yes n.m. n.m. Of the six primary
studies, two reported
a positive outcomes
whereas four were
negative
Gates
(2006)
17
AA Cocaine 7 Low Yes 9 ‘There is currently no evidence
that AA is effective for the
treatment of cocaine
dependence.’
() Yes None
declared
Mentioned The majority of the primary
trials used sham AA
Jordan
(2006)
18
AT Cocaine,
opiates
n.m. Low No 2 ‘[T]here was no significant
evidence
for AT being a more effective
treatment than controls’
() Yes n.m. n.m. Unknown number of primary
trials; lack of validity
assessments; poor overall
quality
Jordan
(2008)
19
TCM Opiates
(heroin)
6 Low to
moderate
No 2 ‘The majority of clinical
evidence... demonstrates
good evidence for TCM
patent medicines in heroin
addiction treatment’
(+) Yes n.m. n.m. Poor quality review; its
findings and conclusions
difficult to interpret
Kim
(2005)
20
AT Cocaine 7 Low to
moderate
No 7 ‘AT is not effective for treating
cocaine addiction as the sole
mode of treatment’
() No n.m. n.m. No eligibility criteria, only
one database used
for searches; highly biased
Lin
(2012)
21
AA, AT, EA Opiates
(heroin,
morphine,
opium)
10 Low No 5 ‘This review cannot be used
to establish the efficacy
of acupuncture in the
treatment of opiate addiction’
(+/) Yes n.m. Mentioned Biased search strategy;
primary data missing
Lua
(2012)
22
AA Amphetamine,
cannabis,
cocaine,
opiates
(heroin)
and various
drugs
8 Low No 3 ‘The overall effectiveness of AA
in treating drug addiction
remains inconclusive’
(+/) Yes None
declared
n.m. A wide variety of drugs were
included; some of the
addicts were on methadone
4 Focus on Alternative and Complementary Therapies
2016 ()
Table 1 (Continued)
First
author
(year)
Intervention(s) Type of
addiction
N*Quality
of RCTs
Meta-
analysis
Quality
of SR
(Oxman
score)
8
Overall result
(quote)
Direction of
conclusion
Mention
of adverse
effects
Conflict
of interest
Source
of funding
Comment
Mills
(2005)
24
AA Cocaine 9 Low to
moderate
Yes 5 ‘This systematic review and
meta-analysis does not
support the use of AT for
the treatment of cocaine
dependence’
() Yes None
declared
n.m. Lack of standardised
sessions of AA, disparate
endpoints and outcomes
Ter Riet
(1990)
26
AT Alcohol,
opiates
(heroin),
tobacco
22 Low No 3 ‘Claims that AT is efficacious
as a therapy for these
addictions are thus not
supported by results from
sound clinical research.’
() No n.m. n.m. The worse the quality
of the primary studies
were, the more positive
outcomes were reported
White
(1999)
28
AA,AT,EA Tobacco 14 Low Yes 7 ‘Acupuncture was not superior
to sham acupuncture for
smoking cessation’
() No n.m. n.m. Low internal validity
of the included trials
White
(2002)
29
AA, AP,
AT, EA, LA
Tobacco 22 Low Yes 9 ‘There is no clear evidence
that AT, AP, LA or EA
are effective for smoking
cessation.’
() No None
declared
Mentioned Acupuncture was more
effective in short term
compared to no treatment
White
(2006)
30
AA Tobacco 13 Low to
high
Yes 9 ‘AA appears to be effective
for smoking cessation,
but the effect may not
depend on point
location’
(+) No n.m. Mentioned There was a considerable
heterogeneity of all
three meta-analyses
White
(2006)
31
AA, AP,
AT, EA, LA
Tobacco 24 Low Yes 9 ‘There is no consistent
evidence whether the
effectiveness of
AT, AP, LA or EA for
smoking cessation is any
different from a placebo
effect’
() No n.m. n.m. There were no effects of
AT compared with sham
AT in both the short
term and long term
White
(2011)
32
AA, AP,
AT, EA, LA
Tobacco 33 Low-
moderate
Yes 9 ‘There is no bias-free,
consistent evidence
that AT, AP, LA or EA
are effective interventions
for smoking cessation.
Acupuncture is less
effective than nicotine
chewing gum.’
(+/) Yes None
declared
Mentioned There was a
reduced risk ratio for
the short-term effect of
AT compared to sham AT
White
(2014)
33
AA, AP,
AT, EA, LA
Tobacco 38 Moderate Yes 9 ‘Although pooled estimates
suggest possible short-term
effects there is no consistent,
bias-free evidence that AT,
AP or LA have a sustained
benefit on smoking
cessation for 6 months
or more.’
(+/) Yes None
declared
Mentioned Continuous AA
was more effective
in the short term
than sham stimulation
Zhang
(2014)
35
AA, AT, EA Opioids 16 Low Yes 8 ‘This review and meta-analysis
could not confirm that
acupuncture was an effective
treatment for psychological
symptoms associated with
opioid addiction’
() No None
declared
Mentioned Low quality of
RCTs; meta-analysis
of one RCT only is being
reported (for depression
associated with
opioid addiction)
Review 5
Table 1 (Continued)
First
author
(year)
Intervention(s) Type of
addiction
N*Quality
of RCTs
Meta-
analysis
Quality
of SR
(Oxman
score)
8
Overall result
(quote)
Direction of
conclusion
Mention
of adverse
effects
Conflict
of interest
Source
of funding
Comment
II: Mind–body interventions
Abbot
(2000)
9
Hypnotherapy Tobacco 9 Low-
moderate
Yes 9 ‘There is insufficient evidence
to recommend hypnotherapy
as a specific treatment for
smoking cessation.’
() No None
declared
Mentioned Studies that favoured
hypnotherapy were
small and
methodologically
flawed
Barnes
(2010)
10
Hypnotherapy Tobacco 11 Moderate Yes 9 ‘There is not enough
evidence
to show whether
hypnotherapy
could be as effective as
counselling treatment.’
(+/) Yes None
declared
Mentioned Wide confidence
intervals of the primary
data; difficult to infer
equivalence
Carim-Todd
(2013)
12
Yoga,
meditation
and
mindfulness
Tobacco 14 Moderate No 7 ‘The small number of studies
available and associated
methodological problems
require more clinical trials
with larger sample sizes and
carefully monitored
interventions to determine
rigorously if yoga and
meditation are effective
treatments’
(+/) Yes None
declared
Mentioned Review also
included non-controlled
trials; 11 of the primary
studies pertained to CAM
Chiesa
(2014)
14
Meditation,
mindfulness,
spirituality
Alcohol,
cannabis,
cocaine,
metham-
phetamine,
opiates,
tobacco
24 Low No 7 ‘[C]urrent evidence suggests
that mindfulness based
interventions can reduce
the consumption of several
substances...to a significantly
higher extent than several
types of active and inactive
control groups’
(+) Yes None
declared
n.m. Of the primary
studies, 14 pertained
to CAM; most of them
suffered from major
methodological limitations
Mays
(2008)
23
Music therapy Alcohol,
various
drugs
5
a
Low No 3 ‘In the literature, no
consensus exists regarding
of the efficacy of music
therapy as treatment for
patients with addictions’
(+/) No n.m. Mentioned Review based on a small
number of pilot studies
Posadzki
(2014)
25
Yoga Alcohol,
tobacco,
various
drugs
8 Low No 8 ‘The evidence in support of
the effectiveness of yoga
for addiction is encouraging
but inconclusive.’
(+/) Yes None
declared
Mentioned Small number of poor quality
RCTs; a variety of addictions
Zgierska
(2009)
34
Meditation Alcohol,
cocaine,
opiates
(heroin)
3
b
Low No 6 ‘Conclusive data for MM
[mindfulness meditation-
based Interventions] as a
treatment for addictive
disorders are lacking.’
(+/) Yes n.m. Mentioned Review also included non-RCTs,
case series, case report and
qualitative studies. A mixture
of psychotherapeutic
approaches had been
included
6 Focus on Alternative and Complementary Therapies
2016 ()
Table 1 (Continued )
First
author
(year)
Intervention(s) Type of
addiction
N*Quality
of RCTs
Meta-
analysis
Quality
of SR
(Oxman
score)
8
Overall result
(quote)
Direction of
conclusion
Mention
of adverse
effects
Conflict
of interest
Source
of funding
Comment
III: Biologically-based therapies
Werneke
(2006)
27
Herbal
medicine
Alcohol,
cocaine,
opiates
(heroin)
4
c
Low No 2 ‘Systematic clinical trials
are needed to test promising
substances’
(+/) Yes None
declared
n.m. Of the four studies included,
two were RCTs and two were
open-label trials
IV: Manipulative and body-based methods
None None None None None None None None None None None None None
V: Energy therapies
None None None None None None None None None None None None None
VI: Miscellaneous
Behere
(2009)
11
CAM in
general
d
Alcohol,
cocaine,
opiates,
tobacco
16
e
Low to
moderate
No 7 ‘More systematic studies are
required before these systems
of medicine can be widely
recommended in the
treatment of substance use
disorders’
(+/) No n.m. n.m. Review also included animal
studies and SRs
AA, auricular acupuncture; AEA, auricular electro-acupuncture; ALA, auricular laser acupuncture; AP, acupressure; AT, acupuncture; EA, electro-acupuncture; LA, laser-
acupuncture; MBM, mind–body medicine; N*, total number of primary studies; n.m., not mentioned; POMs, primary outcome measures; SR, systematic review; +, posi-
tive; , negative; +/, equivocal.
a
All of the primary data referred to as ‘studies’-unclear whether the number pertained to RCTs.
b
Number reflects RCTs of meditative techniques.
c
Number pertains to two trials on addictions only.
d
The review also included dietary supplements.
e
Pertains to the number of RCTs.
Review 7
Table 2 Quality ratings for included systematic reviews of CAMs for addictions
First author
(year)
Search
methods?
(a)
Search
comprehensive?
(b)
Inclusion
criteria?
(c)
Bias
avoided?
(d)
Validity
criteria?
(e)
Validity
assessed?
(f)
Methods for
combining
studies? (g)
Appropriately
combined?
(h)
Conclusions
supported?
(i)
Sum
Abbot (2000)
9
11 11111 1 1 9
Barnes (2010)
10
11 11111 1 1 9
Behere (2009)
11
011111110 7
Carim-Todd (2013)
12
11 11011 0 1 7
Cheng (2012)
13
11 11111 0 0 7
Chiesa (2014)
14
11 11110 0 1 7
Cho (2009)
15
11 11111 1 1 9
D’Alberto (2004)
16
11 11110 0 0 4
Gates (2006)
17
11 11111 1 1 9
Jordan (2006)
18
11 1111110 2
Jordan (2008)
19
11 0011110 2
Kim (2005)
20
011111110 7
Lin (2012)
21
00 11111 0 0 5
Lua (2012)
22
10 1111110 3
Mays (2008)
23
11 1011110 3
Mills (2005)
24
01 11001 1 0 5
Posadzki (2014)
25
11 11111 0 1 8
Ter Riet (1990)
26
11 1011110 3
Werneke (2006)
27
01 11111 11 2
White (1999)
28
11 00111 1 1 7
White (2002)
29
11 11111 1 1 9
White (2006)
30
11 11111 1 1 9
White (2006)
31
11 11111 1 1 9
White (2011)
32
11 11111 1 1 9
White (2014)
33
11 11111 1 1 9
Zgierska (2009)
34
11 1111110 6
Zhang (2014)
35
11 1111111 8
Scoring: each question is scored as 1, 0, or 1. The column headings denoting scoring are identified by the letters (a)–(i) in the explanatory notes below. One means
that: (a) the review states the databases used, date of most recent searches, and some mention of search terms; (b) the review searches at least two databases and looks
at other sources; (c) the review states the criteria used for deciding which studies to include in the overview; (d) the review reports how many studies were identified
by searches, numbers excluded and appropriate reasons for excluding them; (e) the review states the criteria used for assessing the validity of the included studies;
(f) the review reports validity assessment and did some type of analysis with it; (g) the report mentions that quantitative analysis was not possible and reasons that it
could not be done; (h) the review performs a test for heterogeneity before pooling or does appropriate subgroup testing, appropriate sensitivity analysis, or other such
analysis; (i) the conclusions made by the author(s) are supported by the data and/or analysis reported in the review. Zero means that the above-mentioned criteria were
partially fulfilled. 1 means that none of the above-mentioned criteria were fulfilled. This is operationalisation of the Oxman criteria,
8
adapted from Posadzki and Ernst
(2011).
36
8 Focus on Alternative and Complementary Therapies
2016 ()
key data from the included SRs are summarised in
Table 1. Table 2
8–36
presents the methodological
quality/risk of bias of the included SRs.
Characteristics of included studies
A wide variety of CAM modalities were evaluated
such as acupuncture (AT), acupressure (AP), auricu-
lar acupuncture (AA), auricular electro-acupuncture
(AEA), auricular laser acupuncture (ALA), CAM in
general, electro-acupuncture (EA) or laser-acupunc-
ture (LA), herbal medicine, hypnotherapy, medita-
tion, mindfulness techniques, music therapy,
spirituality, TCM and yoga. One SR included evi-
dence from animal studies alongside human tri-
als,
11
and one failed to mention the total number
of included studies.
18
Addictions included alcohol
(n=8), amphetamine (n=1), cannabis (n=2), cocaine
(n=10), methamphetamine (n=1), opiates (n=10),
tobacco (n=14) and various drugs (n=3). Sixteen SRs
evaluated single addictions; the remaining 11 SRs
evaluated more than one type of addiction. Overall,
11 (40.7%) SRs did not mention AEs and 16
(59.3%) did. Thirteen (48.2%) SRs mentioned the
authors’ conflict of interest, and 13 (48.2%)
reported the source of funding.
Effectiveness of CAM modalities in addictions (NCCIH
classification)
Overall, 18 SRs fell under the alternative medical
systems category; these reviews evaluated the fol-
lowing addictions: alcohol (n=2), amphetamine
(n=1), cannabis (n=1), cocaine (n=6), opiates (n=6),
tobacco (n=8) and other drugs (n=1). Of these, three
SRs showed positive results for tobacco and opiate
addiction; 10 SRs showed negative results for alco-
hol, cocaine, opiate and tobacco addiction; and five
SRs showed equivocal results for alcohol, ampheta-
mine, cannabis, cocaine, opiate, tobacco and other
drug addictions. Seven reviews were classified as
mind–body interventions; these reviews evaluated
the following addictions: alcohol (n=4), cannabis
(n=1), cocaine (n=2), methamphetamine (n=1), opi-
ates (n=2), tobacco (n=5) and other drugs (n=2). Of
these, one SR showed positive results for alcohol,
cannabis, cocaine, methamphetamine, opiate or
tobacco addiction; one SR showed negative results
for tobacco addiction; and five SRs showed equivo-
cal results for alcohol, cocaine, opiate, tobacco or
other drug addictions. One review was classified as
a biologically based therapy (herbal medicine); the
review jointly evaluated alcohol, cocaine and opi-
ates, and showed equivocal results. None of the
included reviews were classified as manipulative/
body-based methods or energy therapies. One was
classified as miscellaneous as it included a plethora
of CAM modalities (as well as dietary supplements)
in the management of alcohol, cocaine, opiate and
tobacco addiction, which showed equivocal results.
Risk of bias of primary and secondary studies
In the included SRs, the number of primary studies
(RCTs) ranged from three to 38 (mean=13.3;
SD=9.15). Thirteen high-quality SRs (Oxman score
6–9) were based on poor-quality RCTs; seven were
based on moderate-quality RCTs; and only one was
based on high-quality RCTs. Thirteen SRs (48.1%)
used meta-analysis and 14 (51.9%) did not. The
methodological quality of the included SRs ranged
from Oxman score 9 (poor) to 9 (excellent)
(mean=4.66, SD=5.20). Table 3 summarises the
direction of conclusions as a function of the quality
of the SRs as well as that of the primary RCTs. The
largest number of high-quality SRs arrived at equiv-
ocal conclusions (n=7). The largest number of SRs
that arrived at equivocal or negative conclusions
were based on poor-quality RCTs (n=10). There were
no methodologically flawed SRs (Oxman score 2–3
or 4–5) that would draw unanimously positive con-
clusions. Table 4 summarises the quality of the SRs
as a function of addiction type. The highest num-
ber of methodologically sound SRs focused on
tobacco addiction, followed by alcohol, cocaine,
opiate, cannabis and other drug addictions.
Discussion
This overview of systematic reviews aimed to sum-
marise and critically evaluate the evidence from
SRs of various CAMs for various addictions.
Twenty-seven SRs were included. Only two SRs
(7.4%) had been published before the year 2000
with the remainder (92.6%) published after that
date. The majority of SRs (44.4%) arrived at equiv-
ocal conclusions; 40.7% of them drew negative
conclusions; and only 14.8% arrived at positive
conclusions.
Table 3 The direction of conclusion as a function of quality of
systematic reviews and primary trials
Quality of systematic
review (Oxman score)
8
The direction of conclusion (n)
Positive
(+)
Negative
()
Equivocal
(+/)
Extensive flaws
(≤1)
123
Major flaws
(2–3)
011
Minor flaws (4–5) 0 2 1
Minimal or no flaws
(6–9)
367
Quality of primary trials
Low 4 10 9
Moderate 3 4 5
High 1 0 0
n, number of systematic reviews.
Review 9
There was contradictory evidence to support the
effectiveness of CAM in all addictions. For instance,
three SRs concluded that AT and associated tech-
niques, such as AA, mindfulness, meditation and
spirituality are effective in the management of
tobacco addiction; whereas five SRs drew negative
conclusions for the effectiveness of hypnotherapy,
AA, AP, AT, EA and LA in tobacco addiction. Six
SRs drew equivocal conclusions for AA, AP, AT,
CAM in general, EA, hypnotherapy, LA, meditation,
mindfulness and yoga in tobacco addiction. The
most conflicting evidence was for AA, which is in
line with the previous review.
37
For alcohol and
opiate addiction, the evidence available so far is
predominately equivocal. For cocaine dependence,
it is negative. Overall, the largest number of the
included SRs focused on tobacco addition (n=14);
12 (86%) of those reviews were determined to be of
the highest methodological quality, with the direc-
tion of conclusions predominantly equivocal or
negative.
Various CAM modalities have been investigated
in SRs. Using the NCCIH classifications, alternative
medical systems were the most frequently tested
types of CAM, including AA (n=14), AT (n=12), EA
(n=9), LA (n=6), AP (n=5), AEA (n=1), ALA (n=1) and
TCM (n=1); followed by mind–body interventions
such as meditation (n=3), hypnotherapy (n=2),
mindfulness (n=2), yoga (n=2), music therapy (n=1)
and spirituality (n=1). The remaining SR evaluated
biologically based herbal medicine (n=1).
We used Oxman criteria
8
to evaluate the method-
ological quality of the 27 SRs; 16 were of high
methodological quality, three had minor flaws, two
had major flaws and six had extensive flaws. Over-
all, 59.2% of the included SRs were of high
methodological quality (Table 2). Of these, all but
one drew their conclusions on low- to moderate-
quality RCTs. It may sound counterintuitive but
even the highest-quality SRs are subject to question
and a reader’s confidence in the conclusions can be
significantly undermined if SRs are based on poor-
quality primary RCTs (Table 5).
Some self-regulatory techniques/mind–body med-
icines (MBM) such as meditation, mindfulness or
yoga have been suggested as being effective for the
treatment of addictions; and there might be several
plausible mechanisms of action involved.
25,38,39
For
instance, studies have shown that mindfulness
meditation limits experiential avoidance by inter-
rupting the tendency to respond using maladaptive
behaviours (i.e. substance use).
40
Yoga, for example,
might serve as a direct substitute for the reduced
arousal that follows the consumption of addictive
substances; it may also minimise the reinforcement
of addictive behaviours, increase the sense of con-
trol and cognitive flexibility, improve well-being
and self-esteem and decrease negative emotions.
25
Table 4 The quality of systematic review as a function of addiction type
Type of addiction Quality of systematic review (Oxman score)
8
Extensive
flaws
(≤1)
Major
flaws
(2–3)
Minor
flaws
(4–5)
Minimal or no
flaws
(6–9)
Alcohol 2 2 0 4
Amphetamine 1 0 0 0
Cannabis 1 0 0 1
Cocaine 4 1 2 3
Methamphetamine 0 0 0 1
Opiates (including heroin,
morphine and opium)
4213
Tobacco 1 1 0 12
Various/unspecified drugs 2 0 0 1
Table 5 The quality of systematic review (Oxman score)
8
as a function of quality of primary data
Quality of primary trials Quality of systematic review (Oxman score)
Extensive
flaws (≤1)
Major
flaws (2–3)
Minor
flaws (4–5)
Minimal or
no flaws (6–9)
Low 6 2 2 13
Moderate 3 0 2 7
High 0 0 0 1
10 Focus on Alternative and Complementary Therapies
2016 ()
The beneficial effects of MBM might also involve
self-efficacy beliefs related to the patient’s feelings
of personal empowerment that they can effectively
manage the stressful situation.
It is also worth mentioning that other CAM
modalities, for which no SRs exist, show promise
for various types of addictions. For instance, pre-
liminary evidence supports the effectiveness of
massage as an adjunct to traditional medical
detoxification for alcohol, psychoactive drugs and
nicotine.
41–43
In light of these analyses, it is important to men-
tion the risk–benefit balance of CAM. The majority
of therapies in question have a good safety pro-
file.
44–47
Given the paucity of adverse effects from
MBM and its benefits, the risk–benefit ratio for
meditation, mindfulness and yoga would seem to
be positive for some addictions. A cost–benefit ratio
of CAM for addictions is largely unknown, and
more research is needed in this area.
Considerable challenges exist for addiction
research. The studies included in this overview
highlight the inherent difficulties of conducting
RCTs of behavioural interventions, such as the lack
of blinding, standardisation of treatment packages
and control for placebo effects. Furthermore, com-
parator groups in the RCTs were heterogeneous and
included placebo/sham treatments (e.g. sham AT),
no treatment, pharmacological or non-pharmacolo-
gical treatments (e.g. cognitive–behavioural inter-
ventions), as well as usual care, leading to indirect
comparisons and lower quality of evidence.
48
In
order to advance this area, there needs to be appro-
priately funded, high-quality trials with sufficiently
powered samples, allocation concealment, ITT anal-
ysis, validated and objective outcome measures, suf-
ficiently long follow-ups and cost-effectiveness
analyses. The findings of such RCTs should then be
quantitatively pooled in meta-analyses to guide pol-
icy makers and clinicians.
This overview of SRs has several limitations that
should be kept in mind when interpreting its out-
comes. The principal limitation is that many of
these SRs often analysed the same primary studies
but, confusingly, arrived at different conclusions
(Table 6). Considering this overlap between SRs is
critical when interpreting results of this overview.
One such example is AT, for which different
authors drew contradictory conclusions for similar
datasets; and there was an overlap (double-count-
ing) in terms of primary studies. For instance, 14
SRs focused on AA and the majority of those relied
on the same RCTs. The problem of double-counting
in overviews of SRs is, however, methodologically
unavoidable (i.e. non-Cochrane SRs including large
proportions of the same RCTs already included in
Cochrane reviews and vice versa). Our searches were
limited to the English language, so there is a
possibility that relevant non-English articles were
omitted. Some SRs had methodological weaknesses
and were based on poor-quality primary data
(Table 7). In addition, reviewing SRs might neglect
the nuances that may be hidden in the original
data. Furthermore, all SRs are susceptible to publica-
tion bias within the primary data that they include,
and, therefore, any such bias has been inherited in
our study. Collectively, these limitations render our
findings open to criticism.
Conclusion
To conclude, a large number of SRs of CAM exists
in the area of addiction. Our review suggests that
the evidence of the effectiveness of CAM for addic-
tion is confusing; or negative. Several limitations of
the current evidence have been emphasised. Also
highlighted is the need for more quality primary
RCTs to determine the therapeutic usefulness of
CAM.
Table 6 Types of addictions with multiple systematic reviews
Condition Conclusion (n)
Positive
(+)
Negative
()
Equivocal
(+/)
Alcohol 1 1 6
Cannabis 1 0 1
Cocaine 1 5 4
Opiates 2 3 5
Tobacco 3 5 6
n, number of systematic reviews.
Table 7 The direction of conclusion as a function of CAM modality
Type of CAM Conclusion (n)
Positive
(+)
Negative
()
Equivocal
(+/)
Auricular acupuncture 2 7 5
Auricular electro-acupuncture 0 0 1
Auricular laser-acupuncture 0 0 1
Acupressure 1 2 2
Acupuncture 1 7 4
CAM in general 0 0 1
Electro-acupuncture 1 4 4
Herbal medicine 0 0 1
Hypnotherapy 0 1 1
Meditation 1 0 2
Mindfulness 1 0 1
Music therapy 0 0 1
Spirituality 1 0 0
Traditional Chinese medicine 1 0 0
Yoga 0 0 2
n, number of systematic reviews.
Review 11
Conflict of interest All authors (PP, MMKK,
AMNA, OZ and JC) have no potential or actual
conflicts of interest to disclose.
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Pawel Posadzki, PhD, MSc, BSc, Senior Research
Fellow, Centre for Population Health Sciences, Lee Kong
Chian School of Medicine, Nanyang Technological Univer-
sity, 3 Fusionopolis Link, #06–13 Nexus@One-North,
South Tower, Singapore 138543.
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Olena Zhabenko, MD, PhD, Research Fellow, Centre for
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Josip Car, MD, PhD, DIC, MSc, Associate Professor and
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Review 13
