Complimentary Interventions in Addiction Treatment

I'd like to welcome everybody today's presentation on complementary interventions in addiction treatment. I AM your host, Dr. Donnelly Snipes. In this presentation, we're really quickly in the hour going to explore various types of complementary therapies which can be used in the treatment of chemical and behavioral addictions. Remember that each person is unique and when people use substances in order to get the preferred effects from those substances, what has to happen? Neurotransmitters have to be altered in how much or how little of them are available. So we know that alterations in neurotransmitters are ultimately one of the targets for treatment, helping the body naturally rebalance itself. But not everybody has the same biology. Some people, we've talked before in pharmacology classes about the fact that psychopharmacology, your antidepressants and those sorts of things only work for about 30 to 37% of the population. Why is that? Well, we don't completely know, but we know that there are, there's a significant majority of the population that will not completely respond to psychotherapeutic interventions. So biology is one aspect in addictions treatment. There's also the aspect of biology that if somebody had a pre existing mental health issue, if they had a pre existing disruption in the balance of their neurotransmitters, they may respond differently or they may need additional types of, of complementary approaches. And really when we're talking about complementary, we're getting outside the box and we're saying what can we do to help people stabilize their serotonin, their norepinephrine, their dopamine levels, their GABA levels so they can feel energetic, not overly energetic, but they can also regulate their emotions. Not everybody is willing to take medication. So medication assisted therapy sounds great to some people, but it sounds like a complete no go to others. And this includes some of your psychotherapeutic medications like your antidepressants. We need to be aware of that. And okay, if we've got somebody who is just adamant that they are not going to take a pill of any sort or an injection of any sort, then what do we do to help them achieve recovery? And each person's triggers for use are unique. For some people, if they were taking pill based drugs, then taking pills may be a trigger for use. For other people, if they were injecting then needles, for example, may be a trigger for use. People are typically not going to want to expose themselves, especially self administer any treatments that may serve as a trigger. In this presentation we're going to talk about complementary interventions that are the things that are added to, to complement traditional counseling as well as medication assisted therapy. We're not going to talk about medication assisted therapy in this presentation. We already went over that a couple weeks ago. I'll start with my normal soapbox. When we're working with people who are in recovery, we know that their bodies need to heal. We know that some of the things that are contributing to their symptoms, whether it was caused by long term use of a substance or they had a genetic predisposition or whatever the cause was. We know that a lot of people in early recovery have physiological issues that may contribute to their mood symptoms, which may contribute to triggering a relapse. A lot of people when they are experiencing significant dysphoria, feel like they can't tolerate that distress. So anger, anxiety, depression, grief, trauma, all of those things can be very triggering for people. And any of those symptoms, people in early recovery should be screened for thyroid issues. Thyroid issues, if it's too high, can cause symptoms of anxiety. You know, it's kind of revving you up too low mimics the symptoms of depression. If somebody has a malfunctioning thyroid, no amount of antidepressants is going to help. And if one of the reasons they're using is to self medicate their depression, then we need to make sure that we're addressing that underlying issue. It's not hard to screen for thyroid hormones. That's a simple blood test. Cardiovascular issues can also contribute to feelings of depression and in some people, anxiety. When we're not getting enough oxygen, when we're not breathing deeply enough, when our blood's not circulating well enough because our heart is not pumping efficiently or well, then it can contribute to dizziness, fatigue, irritability. There's a lot of symptoms of depression that mimic symptoms of cardiovascular issues. Likewise, when people have atrial fibrillation or other some other heart issues where it feels like their heart is fluid, fluttering or skipping a beat or doing flip flops that can trigger anxiety in a lot of people. We want to pay attention because if the heart is not getting the oxygen and the nutrients throughout the body, we know there's a breakdown in the factory gonadal hormones. We know that significant ongoing stress, significant ongoing activation of the HPA axis, which also can be caused by substance addiction, substance use and withdrawal that can trigger thyroid issues, that can trigger hypothyroid typically that can cause cardiovascular issues and hardening of the arteries that can cause because of the HPA axis over activation, alterations in the sex hormones, testosterone, estrogen progesterone, or all of those, any of those can contribute to mood symptoms. Chronic pain. A lot of people, even if they weren't abusing opioids, a lot of people have chronic pain. And if, especially if the person was abusing opioids or benzodiazepines, your antianxiety meds, then they may be more prone to experience more pain during that early recovery phase. We need to help them deal with those issues that they may have been self medicating with their addictive behavior. Sleep apnea is typically not caused by long term addiction use, long term stress, et cetera. But we do know that sleep apnea contributes to clinical depression in a lot of people. It's not hard to get screened for sleep apnea, autoimmune and inflammatory issues. Inflammation, especially systemic inflammation like we see in autoimmune conditions, is significantly correlated with depression. Inflammation is also significantly correlated with pain. Pain and depression are significantly correlated with relapse. We need to help people learn some stress management tools, but also do what they can to address some of those autoimmune and inflammatory issues. And then finally, I've already kind of touched on this mental health issues caused by neurochemical imbalances. If somebody has, for example, bipolar disorder and they are not stable on their medications, then when they are in a manic or a hypomanic episode, they may be more impulsive. When they are in a depressive episode, they may be more tempted to self medicate to feel better. So either end of the spectrum could be a relapse trap. We do need to identify these, I call these concurrent more than complementary because they are all your traditional western medicine approaches sort of things. But we do need to recognize that there are a lot of things that can contribute to people's underlying issues. So let's move on to what you are probably expecting and some of your more non traditional treatments that are available. Acupuncture is one of the more widely used alternative therapies within the context of addiction and behavioral health treatment. And this is according to the Substance Abuse and Mental Health Services Administration. It is one of those practices that has even been embraced by a lot of western medicine approaches. I know we used to have an acupuncture team come into the clinic, the residential and IOP clinic, twice per week and people were able to optionally get treatment. They didn't have to, but if they wanted to try, they could. Interestingly, they were very sensitive. And we're going to get to the magnets in a second. But since we did have a fair proportion of people who were also injection drug users. The acupuncturists, when they came, were very sensitive to that. And they would bring something called seeds, which are little magnets that basically apply acupressure. They're magnets that go on the front side and the back side of the ear, and they, they squeeze on that pressure point. And obviously magnets affect electrical conduction and everything as well. But it's important to recognize that not everybody is going to be okay with acupuncture because it may be triggering for them or they may just have a fear of needles. Acupressure can be used, magnets can be used. Lasers, they've actually developed laser technology that penetrates below the skin to those nerve areas and activates the meridians. And then electroacupuncture. Now it does use needles, but they've experimented with this. It actually uses two needles in an area and transmits a current between the two needles instead of like twisting the needles or, or other technology that they use. Now, I am not obviously extremely schooled on acupuncture or acupressure. There are articles in the classroom if you want to read more about it. But it is important to recognize that acupuncture has been proven repeatedly to help with a variety of symptoms from addiction, including craving and withdrawal symptoms. Not totally. I mean, it doesn't completely eliminate withdrawal by any means, but it can help a lot with reducing nausea, for example. It can help a lot with mood. And it actually has been shown to reduce cravings and has been associated with a reduction in psychotic symptoms. So how awesome is that? We know that a lot of our atypical antipsychotics and our antipsychotics have significant side effect profiles. And if somebody is able to get a certain amount of relief with acupuncture, that might be super helpful. Acupuncture and acupressure are both well established therapies for pain management. Everything from myofascial pain to low back pain. It's also been established for a variety of different mental health issues. Smoking cessation, it's been tried with a variety of different drugs. You know, people who are trying to quit, a variety of different drugs. So there's a lot of research out there, clinical trials. Interestingly enough, I found out when I was doing some more research this morning, clinical trials are currently underway for treatment of trauma. A lot of people who have traumatic memories avoid those traumatic memories. And because acupuncture, if you stimulate the right meridians, it actually connects with the amygdala and as much as I know, I'm sorry, they're thinking that they may be able to help address that fear response and address some of that learned fear. Anyhow, acupuncture has a lot of options that are available. Acupressure as well. There are also, and I don't know how well they work, they're not like those FDA approved sort of things. I know some people are offering online some of the acupuncture lasers. Like I said, I don't know how well they work, but it would be interesting to take a look at. So what do we know about acupuncture? I've talked about, you know, what it possibly can do, but how does it do it? Acupoints are singular areas in the skin that have been identified as being the external accessible places related to internal organs. Manual acupuncture which is using the needles activates nerve signaling, particularly when the muscle tissue is injured locally by needling. So those little tiny needles that they put in, obviously that registers as damage. This causes the release of pro inflammatory mediators such as histamine and guess what, our favorite 5ht, which is serotonin. So that's kind of interesting. When somebody is initially stuck with the needle, it causes the release of pro inflammatory mediators. It increases circulation to that area. And one of the things that they talk about in traditional Chinese medicine, for example, is making sure that the qi can flow through the body. And by causing that damage, you're increasing circulation to that area, which might be helpful. Think about if you've ever had a clog somewhere and you've turned on the water hard enough to push it out of the way. That's kind of how I think about it. But that may be one way to help the body eliminate blockages in the meridians. In electroacupuncture, depending on the frequency of the electric shock, it activates the nerves without tissue damage. They're not shocking them enough to burn the skin or anything, enabling the pain modulation, which increases several neurotransmitters, including the endogenous opioids, which is one of the reasons that a lot of people use substances is for that high that's produced by the endogenous opioids. The endogenous opioids also address pain. We know that. So they've got a double, double whammy there. And if one of the reasons they're using is for pain, you know that's helpful. And serotonin, serotonin is increased, which helps the person theoretically in this particular case, it's the serotonin receptors that are supposed to help with pain modulation and relaxation. And dopamine is also thought to be increased during acupuncture or acupressure. We know that for the longest time we've talked about dopamine being a neurochemical that's involved in the addiction process. So acupuncture, acupressure, that's out there, it's well studied right now. I'll tell you, it is one of the only ones that is well studied as a complementary or an alternative treatment. Now, there is. There are things out there for chiropractics and massage and things like that. Those are more for pain management and helping people relax. You could argue that chiropractics has some other benefits. I couldn't find any articles on that, so I left that one off of this presentation. If you know a chiropractor who, you know has done work with people who are in recovery, who wants to talk about it, you know, send them my way. Anyhow, brain modulation, this is a new field that is becoming more and more popular and, well, not new. They had electroconvulsive therapy way back in the day. You know, we've really largely gotten away from ect, and the ECT of today is a kinder, gentler ect. However, what we're talking about here is our four different things. Transcranial magnetic stimulation, or tms. You've probably heard of it. If you're in one of the bigger cities like Nashville, there are a lot of TMS clinics that are popping up around EEG and FMRI neurofeedback. That's a relatively not new, but it is a treatment that is more prominent, doesn't require, especially the EEG part, does not require all of the expensive equipment that the FMRI or the TMS require. And deep brain stimulation, which is invasive. That's when they implant the electrodes into people's brains. What do we know about these? Well, there's some limited evidence out there, but the studies are really small. Sample sizes, case studies, sort of anecdotal at best. They're showing some promise. But there isn't enough information out there on any of these to say, oh, yeah, that's something that we have to add to our treatment program offerings. But let's talk about them real quick, because as research progresses, they may be something that you want to keep an eye on. Transcranial magnetic stimulation has shown some promise for reducing cravings in the short term. And with this, they put magnets on the scalp and stimulate the brain through the magnets. Now, EEG is when they put the electrodes on your head and they monitor the electrical activity within your brain. So, you know, that's something we've been doing for a long time. With EEG neurofeedback, though, patients learn to modulate their own brain activity through feedback from the EEG machine. So when they start to get upset, they see certain areas of their brain light up. And when they use their distress tolerance skills, their coping skills, they actually see different areas of their brain light up and the amygdala and some of those other fear stress areas darken again. So they can learn to modulate their own brain activity. They can learn to physiologically dysregulate or reregulate when they become emotionally dysregulated. So that's really, it's really fascinating. These machines are not cheap. You know, you're not just going to go down to, or go online and order one really, really quickly. But it is an extremely useful tool for people who have difficulty, especially with emotional regulation. It is an extremely useful tool. We'll talk about an alternative to that. You know, the cheap alternative in a minute. And then deep brain stimulation. In the case studies, they have reported prolonged abstinence from opioids or alcohol with ventral striatal application of the deep brain stimulation. That is very difficult to get people to volunteer for because most people don't want stuff implanted in their brain. But there have been a few case studies. Now, biofeedback, if you can't afford the EEG and there's nowhere in your county that offers it where patients can go get it, or even if you just want to add layman's alternative, and that's really what this is with biofeedback. They can use a fitness watch or, or a heart rate monitor as well as their respiration rate. You can get one of those little finger monitors to monitor the pulse as well in order to learn how to modulate their physiological stress reactions. When people slow their breathing, their heart rate naturally slows. When you slow your breathing, it triggers what they call rest and digest, encouraging people to become more aware of when their heart rate is kind of creeping up and be able to reregulate it before it's in full blown, panic attack can be really helpful. There have been a lot of studies that have found that biofeedback can help people reduce their systemic hyperarousal. They also increase their feelings of control over their emotions and urges. They start feeling, you know, anxious. That and part of that's with a craving. They feel anxious and hyped up. That I really, I feel like I need to go have that right now. When they use the biofeedback, when they practice slowing their breathing, when they practice slowing their heart rate down and relaxing, it triggers that gaba. It triggers the serotonin. So people start to feel less anxious. When GABA and certain serotonins go up, your dopamine is going to go down. Your dopamine is your craving chemical. So that's cool. And people start to feel like, okay, I can tolerate this. I don't have to feel out of control. They've also found that there's altered information flow from the prefrontal cortex, which is where we do our higher order thinking. It's impulse control. All that's up here to the default mode in the wakeful rest. So instead of the prefrontal cortex saying, hey, get out of wakeful rest. You need to wake up, you need to be stimulated, the information changes and it starts going back to that default mode where it says, okay, you can chill out, you can be daydreaming, you can be relaxing right now. You don't have to be extremely hyper vigilant, which I thought was kind of interesting, but it makes sense. When we use biofeedback, we trigger that rest and digest. And we're not, I mean, if, if you're focusing on what you're, you're breathing, if you're focusing on your heart rate, you're not focused on other things, you're not focused on what's stressing you out. So it makes sense that your relaxation response would kick in. Cbd. Now that's another one of those new buzzwords or buzz treatments, whatever you want to call it out there right now. There is a growing body of preclinical and clinical evidence to support the use of CBD oils for many conditions, suggesting its potential role as another option for treating challenging chronic pain or addiction. They've also found it to be helpful for people with depression and anxiety. Now let's think about it. Remember, in marijuana and cannabis, you have thc, which is the psychoactive component, and then you have cbd, which is relatively non psychoactive. When you buy CBD oil or CBD oils, they are supposed to be absent of any thc. So you're not getting the psychogenic effects of the thc. What you're getting is the cannabidiol, which can go into the brain and trigger those cannabinoid receptors, those receptors that help you feel more relaxed. Those receptors that help you deal with pain, but you're not getting high, you're not having the THC effect from it. So there is some benefit to it. Now I say that, but it's also important to remember that CBD oil can, does alter certain neurotransmitters and it is not recommended to be used in conjunction with other psychotropic medications. And it does interact with like most other medications. So people who are wanting to use CBD oil, number one, need to make sure that they get it from a reputable source that theoretically has done some purity testing to make sure that there's no THC in it or very, very little. And they need to do it, ideally under a doctor's supervision because it can wreak havoc with other medications. So that's, you know, my little warning there. It is an interesting natural alternative for people, again, who don't want to take medications, they don't want to take pills. CBD oil might be an alternative for some people. Cbd, interestingly enough, when people take stimulants like methamphetamine or cocaine, we know that ramps up the HPA axis, the threat response system. We know that cortisol and glutamate are dumped to prepare us to fight or flee. That's part of that excitatory response. We know that when glutamate levels get too high in the brain, it creates what's called an excitotoxic environment. When that happens, we actually are killing brain cells. So it becomes a bad situation. CBD actually prevents drug induced neuroadaptations. It helps buffer that excitotoxicity, which is kind of interesting. Now, I'm not saying that people should add this to their regimen of drug use. No, by all means, we don't want to do that. But it has shown in people in recovery to reverse cognitive deficits and alleviate symptoms of comorbid mental health issues like anxiety and depression. So if it can reverse cognitive deficits, then theoretically, maybe even after somebody quits using, it can help repair, and I'm just speculating here, it can help repair some of those drug induced neuroadaptations. We also know that as a person goes through recovery in time, you know, a year or so, once they get through that post acute withdrawal phase, you know, their brain starts remodeling, you know, when they were using, it created more synapses and remodeled itself in order to handle the onslaught of all those drugs. When they withdraw, then eventually the brain gets the message that, oh, okay, we don't need all these extra receptors up here anymore. So we can, you know, take those down. So it remodels itself again theoretically back to its original state. We can hope. Light therapy is another one that we don't really think of a lot, but it is so important. Light therapy helps reset circadian rhythms. And if you are in the middle of Alaska or if you are in the middle of Florida. Light is important, but not all the time. Our body needs dark hours too. And it's important to be aware of that when, wherever you're at, I can't imagine in Alaska when it never actually gets truly dark. How that must affect people's circadian rhythms. You know, it's really important when they go to sleep, for example, in Alaska when they've got the, you know, 24 hour daytime to be able to block out any light, to sleep with light sleep masks or something. So their brain gets the message that hey, this is, this is sleep time. I digress. Circadian rhythms are responsible for controlling our sleep cycles. When the melatonin secreted how long we sleep, you know, helping us get good quality deep sleep to clear out the adenosine so we can concentrate and focus and have energy. All of those are symptoms of depression when they're out of whack. It controls our hunger when we want to eat. And our hunger and satiation hormones are also regulated by our circadian rhythms to a certain extent. Which is why, you know, some of us, our body, if we eat about the same time every day, our body kind of learns when that time is. That's the circadian rhythm. That's your body saying, okay, it's time to eat again. And cortisol levels are controlled by the circadian rhythms. And we don't want too much cortisol, but we need some, some to help us want to get out of bed when we've got somebody who is in early recovery. A lot of times they have not been regulating their circadian rhythms very well. They may have been staying up into the wee hours of the morning. They may have been staying in dark places all day long, you know, whatever. Most people when they come to treatment often have really out of whack circadian rhythms. So this is something that can be very helpful. We also know that with light therapy people have improved mood and that if you're using bright light therapy, like a light box, that's not increasing the vitamin D. So we do know that there's something about regulating those circadian rhythms that also helps with mood and to stave off sea seasonal affective disorder, sunlight now if you can get out and get sunlight that increases vitamin D naturally. Vitamin D has been shown to improve mood, reduce inflammation. There's that inflammation again. And regulate circadian rhythms. And part of the reason that vitamin D may help improve mood is because it reduces inflammation. But you know, I'll take it. An answer to your question, Laura. They've found that five to 15 minutes of sunlight twice a day is plenty to get enough vitamin D. And it doesn't especially, it doesn't have to be during Those really high UV times, like 9:00am to 3:00pm, you know, you can do it. A lot of people get all their vitamin D when they're walking to their car and to their office in the morning and then, you know, vice versa when they get home and when they're outside, you know, driving. You get sun on your arm, for example, when you're driving. Yeah, you're not getting it all over your body, but it's going through your skin, it's triggering that melanin to do its thing. So, you know, even just getting out can be helpful. You don't need to bask in it. Hypnosis. Some studies have shown decreased craving via hypnotic aversion suggestions through top down regulation of the prefrontal cortex, as evidenced through MRIs. So basically under hypnosis, when an aversive suggestion is implanted, if you want to say that that suggestion is triggered in the prefrontal cortex where we make our higher order thinking, where we control our impulses and everything. And when somebody's had that suggestion implanted and then they're faced with it, let's say nicotine, and then they're faced with the option of having a cigarette. Prefrontal cortex lights up and says, oh no, I don't want that, that's nasty. And so it triggers the body's aversion response, which I think is really interesting. Hypnosis has been used again in a lot of different things for pain control. They use hypnosis in women when they're giving, when they're giving birth. So hypnosis definitely has its place. Hypnosis is one of those things in many states. I wish it were in all states, but in many states it is regulated. It's a licensed practice. You can't just pick up a book and learn how to do hypnosis. You know, that can be not helpful at the very least and harmful at the very worst. People who practice hypnosis have had significant training on how to do it, how to do it safely and what needs to happen, how to actually Create this hypnotic aversion in the context of treatment. Now lastly, we're going to talk a little bit about Kratom. Kratom is a really popular topic right now and it's important to talk about it. You know, I want to put it out there because some people are still using Kratom to self detox from opioids or alcohol. Currently not a medically approved approach. And you know, if you go online, if you look for Kratom and you look for detox, you will find information about it. You will find people are doing it. The people who are believers in Kratom are very fervent believers and they believe it's safe. They believe it is, you know, the thing, they believe it is the best option. The research is slim at best out there. So are we saying that it is horrible to use? You know, some people have used it safely, but currently it is not a medically approved approach. Kratom can cause effects similar to both opioids, the pain control and stimulants. So it can produce sedation, pleasure and decreased pain. It depends on the dose that the person is taking. At a lower dose it will, you know, decrease pain and also make them feel more energized. At higher doses it produces sedation. It is not illegal in the US and not regulated for purity or potency by the fda, which means you don't really know what you're getting when you order Kratom. It's like a lot of things that are over the counter supplements that you're taking. They are not regulated for potency or purity. And, and so you could take one dose and get X amount and take another dose and get 10 times that amount because there wasn't a lot of regulation with it. That is one of the biggest concerns. From what I was reading on the FDA's website, that was one of the biggest concerns from the FDA is that number one, people are self administering and that could be dangerous in and of itself. Detoxification from opioids, typically not life threatening. Detoxification from alcohol can very quickly become life threatening. And if people are trying to detox themselves, they may not see some of the early warning signs. So, you know, that's something to be aware of. But if you're taking the Kratom and you take a dose that happens to have a lot more Kratom in it than you were expecting, it can cause undue sedation. Kratom takes effect after five to ten minutes and the effects last for two to five hours in animals. It appears to be more potent than morphine. So let's think about that. If you're taking something that's more potent, more potent than morphine, and we know all the problems that with addiction that we have to morphine and your other opioids, then let's think about whether Kratom has addictive potential. Yes, it does. Kratom is going in there and messing with those neurotransmitters. And again, I say, I know there are people out there who are firm believers and, and they love this stuff and it's available, it's not illegal. However, it's dangerous. It's one of those things that's kind of dangerous to play around with, especially if the person is detoxing from alcohol or on any other kinds of medications that someone could be on. Addiction is a biopsychosocial condition. When we are working with people, when we talk about, well, when I talk about complementary interventions, I am talking about using an integrative approach to complement. For example, if somebody has hypothyroid addiction and depression, we are going to want to use multiple different things. We're, we're going to need to help them get their thyroid levels regulated and that may help with their mood, but they're also probably going to need talk therapy, cognitive, behavioral, whatever you use in order to help them address some of their addiction and depression issues. No single treatment or intervention is likely sufficient for, for sustained recovery. Having somebody who has a problem with addiction and saying, okay, just go to 12 step meetings or just go to talk therapy or just take medication assisted therapy, that's likely not going to cut it because addiction impacts the body, it impacts our thinking, it impacts our emotions or our neurotransmitter levels which impact our emotions, it impacts our relationships, it impacts our finances. You know, there are a lot things that get impacted by addiction. So it's very unlikely that we can just throw one thing at it and say, okay, you know, this will work. It's also very unlikely, even more unlikely that we're going to find any treatment that works for every person. We need to be very sensitive to people's individual needs. Many complementary therapies help rebalance neurotransmitters and the central nervous system, which issues here often underlie craving and withdrawal symptoms and mood issues which the person is self medicating. Remember, when people use it, they're taking a toxin into their body. Their body registers this as a threat, activates that HPA axis. A lot of times your depressants are going to slow it, but your body alters the neurochemicals significantly in response to the drug that's being taken. When that drug leaves the system, the body doesn't respond by automatically ramping back up its own production. So the person feels withdrawal symptoms. And because of what's causing those withdrawal symptoms is largely an imbalance in neurotransmitters, then we're also not unexpectedly going to see concurrent mood symptoms. Because when neurotransmitters are not in balance, we have mood symptoms. Many therapies can be used in conjunction. You don't have to choose just one. Matter of fact, like I said, a lot of times I'll have three or four things that people are doing to address the myriad of underlying issues contributing to relapse risk, depression, anxiety, low self efficacy, insomnia and fatigue and pain. So those are all issues that may need to be addressed in people when they are in early recovery. When they're in recovery. And we may need to use complementary interventions, talk therapy or medication assisted therapy or the two of them combined are probably not going to be enough to handle everything. Are there any questions? Okay, I will go in in a minute and look at that error message that you're getting. Oh, can I explain tens? Transcutaneous electronic nerve stimulation, One of my favorites. You can actually, you actually can get really good TENS units over the counter now, which is nice. You put little electrodes on and you've got a little battery operated pack that's attached to it. When you turn on the battery operated pack, it sends little electrical pulses through the electrodes by bombarding the, the nerve endings with the stimulation. And it just feels like somebody's tapping on you. It doesn't hurt a bit. It blocks the pain signals from, from going to the brain and it helps the muscles relax. So TENS for musculoskeletal pain, TENS units can be super helpful for people. Obviously, you know, it's technically a medical device. They need to be advised to consult with their physician. However, it is one of those things that you can get online. You can get it. I think you can even get some at stores like Target and Walmart and stuff now too. So those are, that is an option for people who have chronic musculoskeletal pain. Now if they have nerve based pain, it's not going to do a dagum thing for it. Probably it may, but a lot of times it's hard to find the point to stimulate for nerve based pain. Great question. How can the training of medical professionals increase awareness of addiction issues to work with treatment programs? They've got to be willing. And that's been one of my big complaints for many years, that we really don't teach much about addiction, despite the fact that if you include smoking, eating disorders, gambling in the addictive category, you know, you've got a majority of people that you're seeing in clinic who probably have some level of addictive behaviors. I wish they would start offering more. Making it available in continuing education, obviously, is one approach to encouraging medical professionals to be more aware. And part of it is just reducing the stigma because a lot of professionals, not just medical professionals, a lot of professionals still somewhere in the back of their mind, ascribe to the moral model of addiction and believe that it is a moral failure or it's a choice or it's a lack of willpower. And we really need to overcome that to help them understand that there is a physiological, a significant physiological component to it. So that's the long version of. I'm not sure how to increase their training early on, but making them aware and educating our clients is also really important. I had one client, for example, I was working with who had an addiction issue, but was also struggling a lot with depression and interestingly enough, erectile dysfunction. And turns out that erectile dysfunction dopamine is actually involved in, to a certain extent in ed. So, you know, encouraging him to go back and talk to his doctor about and he also had restless legs, encouraging him to talk with his doctor about what was going on and also inform his doctor about his addiction issues to give the doctor the full perspective. I think that helped. I mean, the doctor was very open to the notion that some of the addiction addictive behaviors may have been a form of self medication for this lack of dopamine that was causing the erectile dysfunction. And the restless legs turned out once he was on an antidepressant and his anxiety levels went down, restless legs seemed to be more of an anxiety thing than actually truly restless leg syndrome. So it was an interesting exercise for all of us. But patients sometimes have to advocate for themselves with their doctors and that will spur the doctors on to do a little bit of research. If this podcast helps you help your clients or yourself, please support us by purchasing your ceus@allce.com or getting your agency to sponsor an episode. A direct link to the on demand CEUs for this podcast is@allce.com podcastceus that's allce.com podcastceus to sponsor an episode of Counselor Toolbox and reach over 50,000 clinicians per week. Go to allce.com sponsor. Thank you.