Arts Strategies for Addressing the Opioid Crisis: 

Examining the Evidence

Key Findings from a Literature Review and Program Scan on the Arts, 

Pain Management, and Substance Use Disorder

Arts Strategies for Addressing the Opioid Crisis:

Examining the Evidence

Key Findings from a Literature Review and Program Scan on the Arts, 

Pain Management, and Substance Use Disorder
October 2020

National Endowment for the Arts

400 7th Street, SW

Washington, DC 20506

202-682-5400

arts.gov

Produced by the Office of Research & Analysis

Sunil Iyengar, Director

Patricia Moore Shaffer, Supervisory Program Analyst 

Patricia Germann, Research Administrative Officer

Melissa Menzer, Program Analyst

Editorial assistance by Rebecca Sutton

Designed by Kelli Rogowski

Prepared by Colleen Morrison, Kirsten Keene, and Julie Leis, James Bell Associates 

The authors wish to acknowledge their expert consultant, Joke Bradt, Drexel University, and the following members 

of the study’s technical working group, who provided valuable insights and suggestions:

Tyrone Borders, Professor and Foundation for a Healthy Kentucky Endowed Chair in Rural Health Policy, University 

of Kentucky; Holly Feen-Calligan, Associate Professor and Coordinator of Art Therapy, Wayne State University; 

Dennie Palmer Wolf, Principal Researcher, WolfBrown; Kaile Shilling, Executive Director, Arts for Incarcerated 

Youth Network; Michael J. Silverman, Program Director and Professor of Music Therapy, University of Minnesota; 

Jill Sonke, Director, Center for Arts in Medicine, University of Florida; Ryan Stubbs, Research Manager, National 

Assembly of State Arts Agencies; and Jacob Tebes, Professor of Psychiatry (Psychology) in the Child Study Center, 

Yale School of Medicine.

In addition, the National Endowment for the Arts would like to thank members of the federal Interagency Task Force 

on the Arts and Human Development for their input—in particular, Elizabeth Hoffman and Gaya Dowling from the 

National Institute on Drug Abuse at the National Institutes of Health (NIH)—as well as Wendy Smith from NIH’s 

Office of Behavioral and Social Sciences Research.

Cover photo: Mural Arts teaching artist Brad Carney and students from Philadelphia, Pennsylvania's Northeast 

High School install a panel of artist Joe Boruchow's Smoke Signals at 448 North 10th Street. Photo by Steve Weinik, 

courtesy of Mural Arts Philadelphia

202-682-5496 Voice/TTY

(a device for individuals who are deaf or hearing-impaired)

Individuals who do not use conventional print materials may contact the Arts Endowment’s Accessibility Office 

at 202-682-5532 to obtain this publication in an alternate format.

This publication is available free of charge as a downloadable PDF at arts.gov.
Arts Strategies for Addressing the Opioid Crisis: Examining the Evidence 3

Preface 

Before February 2020, opioid abuse and addiction qualified as the most significant 

public health issue in the United States. Now that national attention has shifted from 

this epidemic to a bona fide pandemic, it may be easy to forget how truly devastating 

this particular type of substance abuse disorder is for victims, families, and whole 

communities. However, recent news reports suggest we may be seeing an increase in 

opioid-related mortality in part because of isolation and lack of access to treatment 

due to shelter-at-home protective orders. Although this report was commissioned long before COVID-19 erupted, 

it shows that results are promising when arts strategies were integrated thoughtfully with clinical and communitybased health solutions. Given the present-day strain on the public health system, these lessons may prove more 

valuable than ever before.

For this National Endowment for the Arts report, the researchers combed hundreds of studies spanning 20 years 

to analyze the most rigorous data about the arts’ applicability to issues of substance abuse, addiction, recovery, and 

pain management. In addition to reviewing this literature, the researchers consulted experts, databases, and other 

sources to identify model programs throughout the report. Lastly, the authors describe research opportunities 

which, if pursued, would strengthen the evidence base for arts interventions used to combat the opioid problem.

Across all arts-based approaches, music programs and music therapy attracted the most numerous and rigorous 

studies about the benefits to substance abuse prevention, recovery, and pain management. The relationship of the 

arts to health outcomes more broadly is the focus of an ongoing research partnership between the Arts Endowment 

and the National Institutes of Health (NIH), through targeted grants on this topic since 2019. 

In addition, resulting from the “Sound Health” partnership with NIH and the John F. Kennedy Center for the 

Performing Arts, the Arts Endowment supports the Sound Health Network, a national initiative at the nexus of 

music, neuroscience, and health and wellness. Music therapy practice and research are also critical to Creative 

Forces: the NEA Military Healing Arts Network, a partnership with the U.S. Departments of Defense and Veterans 

Affairs and state and local arts agencies that seeks to improve the health, wellness, and quality of life of military 

personnel and veterans exposed to trauma.

Trauma is certainly the condition of those grappling with opioid addiction or other substance abuse disorders. This 

Arts Endowment report offers hope through evidence-based resources about the arts’ healing power, even as the 

nation copes with a distinctly different public health crisis.

Mary Anne Carter

Chairman

National Endowment for the Arts
4 National Endowment for the Arts | arts.gov

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Arts Strategies for Addressing the Opioid Crisis: Examining the Evidence 5

Contents

Preface .........................................................................................................................................................................................................................3

Contents ......................................................................................................................................................................................................................5

Exhibits.........................................................................................................................................................................................................................6

Executive Summary.................................................................................................................................................................................................7

Introduction................................................................................................................................................................................................................9

Literature Review..................................................................................................................................................................................................15

Program Scan..........................................................................................................................................................................................................25

Evidence Gaps and Limitations: Moving Forward....................................................................................................................................51

Conclusion................................................................................................................................................................................................................57

Glossary ....................................................................................................................................................................................................................59

Appendix A. List of Studies Included in the Literature Review...........................................................................................................61

Appendix B. Literature Review Methodology ...........................................................................................................................................71

Appendix C. Mixed Methods Appraisal Tool Results ..............................................................................................................................79

Appendix D. Program Scan Methodology ...................................................................................................................................................83

Appendix E. List of Additional Programs for Consideration ................................................................................................................89

Endnotes...................................................................................................................................................................................................................91
6 National Endowment for the Arts | arts.gov

Exhibits

Exhibit 1. The Arts and the Opioid Crisis ....................................................................................................................................................10

Exhibit 2. Music and the Biopsychosocial Model of Care......................................................................................................................11

Exhibit 3. Selected Characteristics of Pain Management Studies .....................................................................................................17

Exhibit 4. Overview of Mixed Methods Appraisal Tool Results for Pain Management Studies ............................................18

Exhibit 5. Selected Outcomes of Pain Management Studies...............................................................................................................19

Exhibit 6. Creative Youth Development Programs..................................................................................................................................20

Exhibit 7. Selected Characteristics of Substance Use Disorder Treatment Studies ..................................................................21

Exhibit 8. Overview of Mixed Methods Appraisal Tool Results for Substance Use Disorder Treatment Studies..........22

Exhibit 9. Selected Outcomes of Substance Use Disorder Treatment Studies ............................................................................23

Exhibit 10. Programs Included in Scan..........................................................................................................................................................27

Exhibit 11. Selected Characteristics of Pain Management Programs..............................................................................................28

Exhibit 12. Rural Veterans TeleRehabilitation Initiative Creative Arts Therapy.........................................................................29

Exhibit 13. Selected Outcomes of Pain Management Programs........................................................................................................30

Exhibit 14. Art Rx...................................................................................................................................................................................................30

Exhibit 15. Selected Characteristics of Substance Use Disorder Prevention Programs .........................................................31

Exhibit 16. Selected Outcomes of Substance Use Disorder Prevention Programs....................................................................32

Exhibit 17. Selected Characteristics of Substance Use Disorder Treatment Programs...........................................................33

Exhibit 18. Selected Outcomes for Treatment Programs .....................................................................................................................33

Exhibit 19. Porch Light........................................................................................................................................................................................56

Exhibit A1. Pain Management Studies..........................................................................................................................................................61

Exhibit A2. Substance Use Disorder Prevention Study .........................................................................................................................67

Exhibit A3. Substance Use Disorder Treatment Studies .......................................................................................................................67

Exhibit B1. Search Terms for Arts-Based Programs and Pain Management.................................................................................73

Exhibit B2. Search Terms for Arts-Based Programs and Substance Use Disorder Prevention .............................................74

Exhibit B3. Search Terms for Arts-Based Programs and Substance Use Disorder Treatment ..............................................75

Exhibit B4. Search Process ................................................................................................................................................................................76

Exhibit B5. Data Abstraction Categories.....................................................................................................................................................77

Exhibit C1. Mixed Methods Appraisal Tool Checklist Overview for Pain Management Studies ..........................................79

Exhibit C2. Mixed Methods Appraisal Tool Checklist Overview for Substance Use Disorder Treatment Studies........80

Exhibit D1. Federal Agency Websites and Search Engines ..................................................................................................................83

Exhibit D2. Search Terms for Arts Programs and Pain...........................................................................................................................84

Exhibit D3. Search Terms for Creative Arts Therapies and Pain........................................................................................................85

Exhibit D4. Search Terms for Arts Programs and Substance Use Disorder...................................................................................86

Exhibit D5. Search Terms for Creative Arts Therapies and Substance Use Disorder................................................................87

Exhibit D6. Criteria for Initial Inclusion........................................................................................................................................................88

Exhibit E1. Programs for Consideration.......................................................................................................................................................89
Arts Strategies for Addressing the Opioid Crisis: Examining the Evidence 7

Executive Summary

In October 2017, the U.S. Department of Health and Human Services declared the opioid crisis a national public 

health emergency and prioritized identifying effective, evidence-based strategies for pain management and the 

prevention and treatment of substance use disorder (SUD).a,1

Increasingly, the arts have become more widely established and accepted as health-promoting practices in the 

United States and around the world.2,3 Research indicates that engagement in the arts has significantly positive 

effects on physical symptoms, psychological health, and social relationships.4,5 As the U.S. healthcare system moves 

toward greater integration of physical and behavioral health6, arts-based interventions should be considered among 

potential complementary approaches for managing pain and preventing and treating SUD. 

The purpose of this report is to describe the evidence on the role of the arts in the management of pain and in 

the prevention and treatment of SUD. Grounded in a literature review and program scan, the report identifies 

promising arts-based strategies to assist individuals, communities, health practitioners, and policymakers in 

responding to the present-day opioid crisis. 

Key findings from the literature review include the following:

• Of the 116 articles that were eligible for inclusion, most (102 articles, or 88 percent) evaluated a musicbased intervention. 

○ Music listening was shown to reduce pain and reduce consumption of pain medication. 

 Of 79 studies that measured the impact of an arts-based intervention on pain reduction, 58 (or 73 

percent) reported a statistically significant positive effect. Of those 58 studies, 51 (or 88 percent) 

evaluated listening to music.

 Of the 17 studies that measured the impact of an arts-based intervention on use of pain medication, 

ten (or 59 percent) reported a statistically significant positive effect. Of those ten studies, all 

evaluated listening to music.

○ Music also was shown to improve readiness and motivation for SUD treatment and to reduce craving. 

 Of the six music therapy studies that measured outcomes related to SUD treatment readiness and 

motivation, four reported statistically significant positive effects.

 Of the five music studies that measured craving, three (two music therapy, one music-listening) 

reported statistically significant positive effects.

• Additional research is warranted to examine the arts’ role in SUD prevention.

○ Research demonstrates that arts-based prevention programs may impact risk and protective factors 

for SUD, including socioemotional development, self-esteem, and academic outcomes. However, 

those studies fell outside the scope of the present literature review because the arts programs did not 

explicitly target or measure outcomes specific to SUD.

Key findings from the program scan include the following:

• Arts-based pain management programs delivered in community and/or healthcare settings target isolation 

and stigma among individuals with pain. Targeting the psychological and social aspects of pain is a potential 

strategy for arts-based programs to support individuals at risk for SUD.

a The definition of SUD and other key terms can be found in the glossary
8 National Endowment for the Arts | arts.gov

• Similarly, arts-based programs address social aspects of SUD, improving community awareness of SUD and 

reducing stigma to promote resilience and recovery. 

Findings from the literature review and program scan highlight several limitations and evidence gaps. To address 

these gaps, a number of directions for future research are recommended:

• Future studies should examine the impact of arts-based interventions other than music. Only a handful 

of studies in the literature review did this. Additional research is needed to inform the evidence base on a 

wider array of art forms and creative arts therapies.

• More studies are needed to assess the maintenance of benefits from arts-based interventions over time. 

Future studies should examine the following questions:

○ Can postoperative, arts-based pain management programs prevent the development of chronic pain and 

disability and/or chronic opioid use and opioid use disorder (OUD)?

○ Can arts-based SUD prevention programs prevent the development of SUD?

○ Can arts-based SUD treatment programs promote long-term and sustained recovery?

• Research is needed to examine the arts’ role in SUD prevention. Programs included in the program scan 

draw on positive youth development theory and practice to help participants develop protective factors 

against SUD. However, a knowledge gap exists between these practices and the empirical evidence base, 

as reported in peer-review journal articles. To measure the impact of their SUD prevention programs, 

arts practitioners and creative arts therapists should collaborate with researchers grounded in program 

evaluation skills and methodologies.

• There is a need for research specifically on individuals with OUD. No studies in this review limited their 

sample to individuals with OUD. While OUD is similar to other types of SUD in many respects, it has several 

unique features. Future research should examine the role of arts-based interventions in the prevention and 

treatment of OUD. 

• Researchers in arts and health disciplines should establish core outcomes, metrics, and reporting 

guidelines. The literature review found great variation in the quality and consistency of reporting. Missing 

information made it difficult to collect and synthesize study characteristics. Creating a shared set of 

core outcomes and reporting guidelines for arts-based interventions would improve research strategies, 

reporting, evidence synthesis, and future collaboration.
Arts Strategies for Addressing the Opioid Crisis: Examining the Evidence 9

Introduction

Opioidsb are natural or synthetic chemicals that reduce the intensity of pain signals and feelings of pain.7 Historically, 

the use of opioids for the treatment of acute pain has been accepted, while their use for managing chronic pain 

has been controversial.8 In the 1990s, U.S. medical practice began a considerable shift toward a more liberal use 

of opioids for chronic non-cancer pain.9 Increased prescription of opioid medications led to a sharp increase in the 

prevalence of opioid use disorder (OUD), which, in turn, contributed to a rise in heroin use and opioid overdose 

deaths.10, 11, 12 Opioid overdose deaths in the United States were five times higher in 2016 than in 1999.13

In October 2017, the U.S. Department of Health and Human Services declared the opioid crisis a national public 

health emergency and announced a five-point strategy with the following priorities:

• Improve access to prevention, treatment, and recovery support services.

• Target the availability and distribution of overdose-reversing drugs.

• Strengthen public health data reporting and collection.

• Support cutting-edge research on addiction and pain.

• Advance the practice of pain management.14

These federal priorities affirm the importance of identifying effective, evidence-based strategies for pain 

management and the preventionc and treatment of substance use disorder (SUD).

Increasingly, the arts have become more widely established and accepted as health-promoting practices in the 

United States and around the world.15, 16 As the U.S. healthcare system moves toward greater integration of physical 

and behavioral health,17 arts-based interventions should be considered among potential complementary approaches 

for managing pain and preventing and treating SUD. For the purposes of this report, the arts encompass various 

branches of creative activity, such as music, painting, literature, and dance. The arts include informal art activities 

(e.g., listening to music), formal art activities (e.g., a music class), and creative arts therapies (e.g., a structured 

therapeutic program using music led by a certified music therapist). 

This report seeks to present available evidence on the relationships between the arts and (1) pain management and 

(2) the prevention and treatment of SUD, including OUD. Drawing from a literature review and program scan, it 

addresses the following research questions:

1. What is the evidence on the role of the arts in pain management?

2. What is the evidence on the role of the arts in the prevention of SUD, including OUD?

3. What is the evidence on the role of the arts in the treatment of SUD, including OUD?

The report will highlight the arts’ potential role in prevention and treatment efforts that respond to the opioid crisis 

in the United States (see Exhibit 1). 

b The definition of opioids and other key terms can be found in the glossar

c For the purposes of this report, the term “prevention” is used to refer to both the prevention of substance use and the prevention of the 

transition from substance use to substance use disorder.
10 National Endowment for the Arts | arts.gov

Exhibit 1. The Arts and the Opioid Crisis 

Response to 

opioid crisis

Prevention

Arts-based pain 

management 

programs

Arts-based

SUD prevention 

programs

Treatment

Arts-based 

SUD treatment

programs

The three domains of interest in this report are: 1) the arts and health; 2) pain; and 3) SUD. By examining the 

relationships between arts-based interventions and pain and SUD, we will inform the arts’ relevance to the presentday opioid crisis. Below is an overview of each domain of interest.

The Arts and Health

Arts-in-medicine programs are emerging domestically and worldwide18 as more medical professionals recognize the 

role the arts can play in the healing process. Surveys conducted by the then-named Society for the Arts in Healthcare 

(now the Arts and Health Alliance) found that approximately 45 percent of healthcare institutions had some type of 

arts program in 2004 and 2007. Most programs featured musicians (82 percent), performing artists (46 percent), or 

visual artists (40 percent).19

The arts can influence health through several mechanisms. Originally developed by George Engel in 1977 as a way 

to integrate psychosocial components into medicine, the biopsychosocial model of care integrates the biological, 

psychological, and social characteristics of the individual into our understanding of health and disease.20 Research 

indicates that engagement in arts activities and/or clinical arts-based interventions can positively influence 

biological and psychological health and social relationships.21, 22

To date, music, the most-researched medium of art and healing,23, 24 has been found to do the following:

• Improve blood pressure25

• Improve sleep quality26

• Decrease activity in the hypothalamus-pituitary-adrenal (HPA) axis, the body’s central response system to 

stress27

• Activate parts of the brain that play a role in descending inhibition of pain, such as opioid-rich midbrain 

nuclei28, 29

• Reduce anxiety and pain30
Arts Strategies for Addressing the Opioid Crisis: Examining the Evidence 11

• Reduce depressive symptoms31

• Elicit social bonding32

The biopsychosocial model organizes these outcomes into multiple pathways through which music might influence 

pain, SUD, and OUD (see Exhibit 2).

Exhibit 2. Music and the Biopsychosocial Model of Care

Pain

Substance use disorder

Opioid use 

disorder Social

 · Increase

 social engagement

 · Increase social support

 · Increase therapeutic alliance

Psychological

 · Reduce depression

 · Reduce anxiety

 · Increase motivation

 Biological

 · Increase 

 dopaminergic activity

 · Decrease HPA axis activity

 · Improve sleep

This theoretical framework helps illustrate the potential of the arts to influence these outcomes, but more research 

is needed to understand the pathways between the arts, more broadly, and pain management and SUD.

Pain

Pain is a pervasive and global public health problem. It is the most common reason adults seek healthcare in the 

United States, and pain relievers are the medications most often prescribed by hospital emergency and outpatient 

departments.33 Recent national estimates suggest that the annual cost of pain care exceeds annual costs for heart 

disease, cancer, and diabetes combined.34, 35, 36
12 National Endowment for the Arts | arts.gov

Pain is commonly classified as acute or chronic based on how long it lasts and its connection to tissue injury 

(e.g., damage to muscles, ligaments, or tendons).37 Acute pain often comes on suddenly and has a specific cause. 

Common causes of acute pain include surgery, broken bones, dental work, burns or cuts, and labor and childbirth. 

Acute pain can develop into chronic pain, persisting for months or even years. Chronic pain is often linked to 

conditions such as back and neck pain, osteoarthritis, headache, nerve pain, and fibromyalgia pain. In many 

instances, chronic pain occurs because the underlying physiological condition (e.g., arthritis) is ongoing and 

unresolved. In other cases, chronic pain does not appear to be caused by any disease, injury, or detectable damage 

to the nervous system (e.g., fibromyalgia pain). 

Pain Management

According to the 2015 National Survey on Drug Use and Health, one in three adults used prescription opioids for 

pain in the United States.38 Individuals who receive opioid therapy after an acute problem, such as a surgery or 

injury, sometimes transition to chronic opioid use.d, 39, 40 Chronic opioid use, in turn, increases the risk of OUD and 

overdose.41 Most people who misuse opioids report doing so to relieve physical pain (63 percent).42

A growing number of healthcare professionals and researchers have called for comprehensive pain management 

strategies that include evidence-based, nonpharmacological options. As the Academic Consortium for Integrative 

Medicine & Health Inter-agency Pain Task Force wrote in its 2018 call to action, “Medical pain management is in 

crisis; from the pervasiveness of pain to inadequate pain treatment, from the escalation of prescription opioids 

to an epidemic in addiction, diversion, and overdose deaths.”43 The task force asked for continued research into 

effective nonpharmacological treatments for pain. That same year, the Joint Commission, the nation’s oldest 

healthcare accreditor, began requiring organizations to develop nonpharmacologic pain treatment strategies.44

Acceptable options suggested by the Joint Commission include music therapy.45

In 2019, the Pain Management Best Practices Inter-Agency Task Force, a federal advisory committee established 

by the Comprehensive Addiction and Recovery Act of 2016, released its final report highlighting five broad 

categories for pain treatment. One category—complementary and integrative health approaches—included 

art and music therapy as well as acupuncture and mindfulness.46 The report recommended further research on 

complementary and integrative health approaches to determine their therapeutic value, risk and benefits, and 

mechanisms of action.

Substance Use Disorder

SUD impacts millions of people nationally. In 2018, approximately 20.3 million people aged 12 or older in the 

United States had an SUD related to use of alcohol or illicit drugs in the past year. This includes 14.8 million people 

who had an alcohol use disorder and 8.1 million people who had an illicit drug use disorder.47 The most common 

illicit drug use disorder was marijuana use disorder (4.4 million people). An estimated 2.0 million people had OUD, 

including 1.7 million people with a prescription pain reliever use disorder and 0.5 million people with a heroin use 

disorder.48

d Although there are different definitions of long-term and/or chronic use based on number of prescriptions or days of supply, the prevalenc

of those who transition from opioid initiation to long-term or chronic opioid use is consistent at about 5 to 7 percent for general populations. 

The higher the dose of the medication, the more likely patients are to make this transition. Treatment duration is also important. While the rate 

of long-term use (on opioids one year after receiving opioid therapy) was relatively low (6.0 percent) for persons with at least one day of opioid 

therapy, the rate increased to 13.5 percent for persons whose first episode of use was for more than eight days and to 29.9 percent when the first 

episode of use was for more than 31 days.
Arts Strategies for Addressing the Opioid Crisis: Examining the Evidence 13

The public health effects of prescription opioids (e.g., oxycodone) and illicit opioids (e.g., heroin) are intertwined.49

Heroin is less expensive than prescription opioids, and many who develop OUD from prescription opioids later 

switch to heroin.50 One study found that 80 percent of sampled heroin users said their opioid use began with 

prescription opioids.51

Drug overdose deaths in the United States more than quadrupled from 1999 to 2017. Nearly 70 percent of the 

70,237 drug overdose deaths reported in 2017 involved a prescription or illicit opioid.52 While the statistics on 

overdose deaths are compelling, they do not fully convey the human toll of the opioid crisis. In 2017, an estimated 

2.2 million children and adolescents were in crisis due to a parent’s OUD.

53 Children and families impacted by 

OUD face a myriad of adverse consequences, including increased risk of mental health problems and drug use; 

accidental opioid poisoning; increased risk of developing an SUD; and family dissolution that results from parents’ 

incarceration, foster care placement, or loss of parent to an opioid overdose.54 The risk of death and other significant 

consequences of OUD, including intergenerational effects, underscore the importance of preventing and treating 

SUD.

Substance Use Disorder Prevention and Treatment

Evidence-based programs aiming to prevent SUD target risk factors and enhance protective factors. Many risk 

factors associated with SUD in young people also predict other problems, including delinquency, mental health 

conditions, violence, and school dropout.55 Therefore, even programs focused on other issues impacting youth may 

help prevent SUD. Likewise, a range of factors may help to prevent adolescent substance use, including individual 

factors, such as having goals and aspirations for the future, and environmental factors, such as connections to 

prosocial peers.56 Prevention can also take root in healthcare settings that use safe prescribing practices, which have 

been shown to reduce overdoses involving prescription opioids.57

Treatment programs for patients with SUD are designed to help individuals stop or reduce harmful substance 

misuse, improve their health and social functioning, and manage their risk for relapse. In 2018, only about 10 percent 

of Americans with SUD received substance use treatment at a specialty facility.58 Among those who did receive 

treatment, completion rates were low (41 percent)59 and relapse rates were high (40–60 percent).60 There is a great 

need to improve access to and effectiveness of SUD treatment. 

Current Report

Previous research has examined the association between the arts, pain management, and SUD treatment. Although 

a meta-analysis and three systematic reviews reported positive results for music’s impact on pain61 and SUD 

treatment,62, 63, 64 they excluded other art forms. Similarly, most reports include only studies using randomized 

controlled trial (RCT) or controlled clinical trial designs. As a result, these reviews may have missed literature that 

can inform the relationships between the arts, more broadly, and pain management and SUD.

This report aims to describe the state of the evidence concerning the relationships between the arts and (1) pain 

management and (2) the prevention and treatment of SUD. Drawing from a literature review and program scan, it 

will explore the arts’ possible role in prevention and treatment efforts and highlight existing program strategies to 

support individuals at risk for OUD.
14 National Endowment for the Arts | arts.gov

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Arts Strategies for Addressing the Opioid Crisis: Examining the Evidence 15

Literature Review

An integrative literature reviewe was conducted to summarize and synthesize empirical research on the arts 

and pain management, SUD prevention, and SUD treatment. This chapter summarizes key findings by research 

question. It then presents methods used in the literature review and detailed results, also organized by research 

question. A list of studies reviewed can be found in appendix A.

Overview of Key Findings 

This section presents key findings by research question. 

Research Question 1. What is the evidence on the role of the arts in pain 

management?

Key finding: The evidence suggests that listening to music may reduce pain and the use of pain medication. 

• The search process resulted in 79 studies on the topic of pain management. 

• Of the 79 studies, 72 evaluated a music-based intervention. Of these 72 studies, 65 evaluated listening to 

music.

• Of the 79 studies that measured the impact of an arts-based intervention on pain reduction, 58 reported 

a statistically significant positive effect. Of those 58 studies, 51 evaluated listening to music.

• Of the 17 studies that measured the impact of an arts-based intervention on use of pain medication, ten 

reported a statistically significant positive effect. Of those ten studies, all evaluated listening to music.

Research Question 2. What is the evidence on the role of the arts in the prevention 

of SUD, including OUD?

Key finding: Additional research is needed to examine the role of the arts in the prevention of SUD. 

• The search resulted in one study on the topic of SUD prevention, so no conclusion can be drawn.

○ Research demonstrates that arts-based prevention programs may impact risk and protective factors 

for SUD, including socioemotional development, self-esteem, and academic outcomes. However, 

these studies fell outside the scope of present literature review because the programs did not 

explicitly target or measure outcomes specific to SUD.

Research Question 3. What is the evidence on the role of the arts in the treatment 

of SUD, including OUD?

Key finding: Music-based interventions, such as group music therapy, may improve readiness and motivation for 

SUD treatment and reduce craving.

e An integrative review employs a systematic approach to search for literature and allows for the inclusion of diverse methodologies (i.e.

experimental and nonexperimental research). For more information, see Robin Whittemore and Kathleen Knafl, “The Integrative Review: 

Updated Methodology,” Journal of Advanced Nursing 52, no. 5 (2005): 546–53.
16 National Endowment for the Arts | arts.gov

• The search process resulted in 36 studies on the topic of SUD treatment. 

• Of the 36 studies, 30 evaluated a music-based intervention. Of these 30 studies, 26 evaluated group 

music therapy.

• Of the six music therapy studies that measured outcomes related to SUD treatment readiness and 

motivation, four reported statistically significant positive effects.

• Of the five music studies that measured craving, three (two music therapy, one music listening) reported 

statistically significant positive effects.

Methods

An integrative literature review was conducted to summarize and synthesize empirical research on the arts and 

pain management, SUD prevention, and SUD treatment. The review did not aim to assess clinical effectiveness of 

a specific intervention, so a meta-analysis was not conducted. The search strategy included a search of publication 

databases, using a combination of search terms. The database searches produced 879 studies, of which 51 were 

eligible for inclusion. Researchers also performed backward and forward reference searches, identifying and 

retrieving additional sources (including gray and white literature) by following chains of citations and sources 

identified in the initial search; this yielded an additional 54 articles eligible for inclusion. Finally, 13 additional studies 

were identified through table of contents searches of select journals, for a total of 116 articles eligible for inclusion 

in the final report. See appendix B for detailed methods. 

To be included in this review, studies had to meet the following criteria:

1. The intervention or program emphasized use of the arts to manage pain or to prevent or treat SUD;

2. The intervention or program had a goal of managing pain or preventing or treating SUD;

3. The article discussed outcomes specific to managing pain or preventing or treating SUD;

4. The article was published in English; and

5. The article was published between January 1999 and July 2019. 

Abstracts were screened and excluded if the study sample did not represent the target population (i.e., individuals 

at risk for OUD or other SUD). For example, studies of individuals receiving palliative care and studies that include 

young children were excluded, including studies of infants with neonatal abstinence syndrome. Pain management 

studies were also excluded if the sample was not a clinical population (e.g., experimentally induced pain). In total, 116 

studies met the inclusion criteria. 

For each study, necessary data were reviewed and abstracted and a Mixed Methods Appraisal Tool (MMAT)f, 65

checklist was completed to inform the quality of the evidence (e.g., type and quality of methodological design). The 

MMAT includes five individual checklists, one each for qualitative studies, quantitative randomized controlled trials, 

quantitative nonrandomized studies, quantitative descriptive studies, and mixed methods research studies. Each 

checklist includes five design-specific quality criteria and guidance for appraising the presence or absence of each 

item. The results section includes aggregate MMAT results for each research question. Appendix C contains detailed 

MMAT results. 

f The MMAT checklist was selected because it was developed to provide a quality appraisal of quantitative, qualitative, and mixed method

designs, all of which are represented in this review. Other frameworks, such as Grading of Recommendations, Assessment, Development, and 

Evaluations, cannot be applied to mixed methods designs. 
Arts Strategies for Addressing the Opioid Crisis: Examining the Evidence 17

Results

This section presents results by research question. 

Research Question 1. What is the evidence on the role of the arts in pain 

management?

The search process resulted in 79 studies on the topic of pain management. 

Study Characteristics 

Most pain management studies were conducted outside the United States and evaluated a music intervention that 

targeted postoperative pain. The intervention typically involved passive participation,g such as participants listening 

to music on their own. A study in Greece, for example, examined the effect of listening to 30 minutes of researcherselected classical music through earphones on postoperative pain among inpatients (n = 87) recovering from major 

abdominal surgery.66 Exhibit 3 summarizes selected study characteristics. 

Exhibit 3. Selected Characteristics of Pain Management Studies (n = 79)

Characteristic Description Number Percentage Notes

Location

International 54 68 Common countries: Iran (n = 9); United Kingdom 

(n = 5); Sweden (n = 4); Turkey (n = 4); China (n = 4)

United States 25 32

Art form

Music 72 91

Other 7 9

Other arts forms: dance (n = 2); literature (n = 1); 

poetry (n = 1); drawing (n = 1); museum tours (n = 1); 

painting/beadwork/crafts (n = 1) 

Participation

Passive 68 86 Activities: listening to music (n = 66); taking museum 

tours (n = 1); reading poetry aloud (n = 1)

Active 11 14

Activities: music therapy (n = 4); dance (n = 2); singing 

(n = 2); drawing (n = 1); music improvisation (n = 1); 

painting/beadwork/crafts (n = 1)

Program 

format Individual 71 90

Target 

population

Individuals with 

postoperative pain 46 58

Common surgeries: gynecological procedures/cesarean 

section or childbirth (n = 10); abdominal (n = 7); cardiac 

(n = 5); hernia or varicose veins (n = 4)

Individuals with 

chronic pain 25 32 Specified conditions: fibromyalgia (n = 3); burns (n = 3); back pain (n = 2)

Individuals with 

cancer pain 8 10

Note: Characteristics are not mutually exclusive. 

g Active participation is defined as being involved in artistic production by making, doing, or creating something. Passive participation i

defined as not being involved in creative expression. For more information, see Alan Brown, Shelly Gilbride, and Jennifer Novak, “Getting In on the 

Act: How Arts Groups Are Creating Opportunities for Active Participation,” The James Irvine Foundation, San Francisco (2011)
18 National Endowment for the Arts | arts.gov

Methodological Quality 

Among the 54 studies using an RCT design, all missed the MMAT design criterion of blinding outcome assessors 

to the provided intervention. Because pain is typically measured through self-report, the participant is often the 

outcome assessor. And because participants typically know whether they received an art intervention, they are 

often not blinded to the intervention. If this item is excluded from the MMAT, 29 (54 percent) RCTs met all quality 

criteria. Second to blinding, the most frequently missed criteria were if randomization was appropriately performed 

and if groups were comparable at baseline. Exhibit 4 presents an overview of MMAT results. See appendix C for a full 

report.

Exhibit 4. Overview of Mixed Methods Appraisal Tool Results for Pain Management 

Studies (n = 79)

MMAT category Number Percentage Percentage meeting all quality 

criteria for study design

Qualitative 1 1 100

Quantitative randomized controlled trial 54 68 0

Quantitative nonrandomized 15 19 23

Quantitative descriptive 2 3 50

Mixed methods 7 9 71

Note: All RCTs missed the design criterion of blinding outcome assessors to the provided intervention by asking participants to self-report pain.

Study Outcomes

All 79 studies measured pain. Overall, 58 studies (73 percent) reported a statistically significant positive impact on 

pain reduction (see Exhibit 5). Statistically significant positive results were reported by 36 studies (78 percent) of 

postoperative pain, 6 studies (75 percent) of cancer pain, and 16 studies (64 percent) of chronic pain.

Of the 17 studies that measured analgesic use, ten studies (59 percent) reported a statistically significant positive 

effect. For example, a study in Iran found that, compared with a control group (n = 30), participants who listened to 

researcher-selected music during urological or abdominal surgery (n = 30) had lower postoperative pain levels and 

lower consumption of narcotic drugs.67
Arts Strategies for Addressing the Opioid Crisis: Examining the Evidence 19

Exhibit 5. Selected Outcomes of Pain Management Studies (n = 79)

Outcome

Measured Statistically significant 

positive effect Notes

Number Percentage Number Percentage

Overall pain 

reduction 79 100 58 73

Postoperative 

pain reduction 46 58 36 78

Chronic pain 

reduction 25 32 16 64

Cancer pain 

reduction 8 10 6 75

Mental health/

well-being 40 51 28 70 Includes depression, anxiety, stress, 

relaxation, hope, etc.

Analgesic use 17 22 10 59

Physiological 

parameters 10 13 6 60 Includes blood pressure, heart rate, 

respiratory rate, serum cortisol, etc.

Note: Outcomes are not mutually exclusive; many studies measured multiple outcomes.

Research Question 2. What is the evidence on the role of the arts in the prevention 

of SUD, including OUD?

The search resulted in one study68 on the topic of SUD prevention. 

Study Characteristics

The study (n = 283) used a single-group pre-/posttest design to examine whether attending a theater production 

about substance abuseh would increase awareness and understanding of the risk and protective factors associated 

with alcohol and other drug use. The authors also assessed if attendance was associated with participation in 

substance abuse prevention activities, such as volunteering or donating money to organizations that target 

substance abuse prevention or treatment.

Study Outcomes

Results indicate that viewing the play increased participants’ knowledge of substance abuse as a disease and 

increased their intent to participate in substance abuse prevention activities at home and in the community. 

hThe term “SUD” is used throughout this report in accordance with the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) definitio

published in 2013. When describing specific studies, many of which were published before 2013, the author’s original language is used. In 2015, 

the International Society of Addiction Journal Editors recommended against using stigmatizing terminology, most notably “abuse” and “abuser,” in 

published addiction science. For more information, see The International Society of Addiction Journal Editors, Statements and Guidelines, 

http://www.isaje.net/addiction-terminology.html
20 National Endowment for the Arts | arts.gov

Follow-up surveys conducted three months after the play indicate that participants increased their participation in 

substance abuse prevention activities, particularly by donating money.69

The fact that the search resulted in only one study might suggest the following: 

• SUD prevention programs that implement arts-based activities as part of their curricula do not emphasize 

the arts as the main “ingredient” or driver of outcomes. 

• Arts-based prevention programs do not explicitly connect their program goals and activities to SUD prevention. 

• Arts-based prevention programs do not measure and/or report outcomes related to SUD prevention.

Related Research

Several potentially promising programs—including prevention programs that do not explicitly target SUD but do target 

important risk and protective factors—fell outside the scope of this review. For example, participation in arts activities 

has been found to promote children’s socioemotional development, resilience, and mental well-being70, 71, 72—all of 

which may protect against SUD.73 Cultural arts programs have been found to support youth in the juvenile justice 

system in acquiring adaptive social, vocational, and emotional skills that foster self-esteem and self-efficacy and 

reduce interest in committing crimes.74

Similarly, creative youth development programs combine community arts education and positive youth development 

practices to foster life skills such as leadership, teamwork, and communication. Creative youth development 

programs have been found to positively impact academic outcomes, increase school engagement, and reduce the 

likelihood of school suspension.75, 76

Targeting risk and protective factors is one potential strategy that arts-based programs can use to support 

individuals at risk for OUD (see Exhibit 6).

Exhibit 6. Creative Youth Development Programs

Creative youth development programs blend art techniques with positive youth development practices 

to help young people build protective factors, achieve their goals, and transition to healthy, productive 

adulthoods. By establishing creative outlets for participants, program leaders hope to facilitate goal setting 

and positive decision-making that may help prevent youth SUD.

“It’s like a marriage. We try to be as equal with our youth development as we are with our dance technique,” 

says Charné Furcron, director of education for Moving in the Spirit. The Atlanta-based program offers youth 

dance classes with a focus on kinesthetic learning and nonverbal communication. For example, a teacher 

might ask students to perform movements that depict them turning down prescription opioids offered by 

their peers. The class might then transition into a reflection phase to discuss the feelings and thoughts they 

had while performing the movement. 

In Albuquerque, New Mexico, the M3 program (shorthand for Movement + Mentorship = Metamorphosis) 

takes a similar approach to helping youth grow through dance and mentorship. The Keshet Dance Company 

delivers M3 to young people at the state-run juvenile detention facility. Mentors regard participants as 

fellow artists, not as inmates or juvenile delinquents, says founder and artistic director Shira Greenberg. 

The Prodigy Cultural Arts Program in Tampa, Florida, serves some adjudicated youth but primarily delivers 

services at community-based sites across eight counties. The program offers dance, painting, photography, 

sculpting, music, theater, and more to deliver what director Mike Trepper calls “life skills–infused cultural arts.” 

“[Prodigy Cultural Arts Program] provides a variety of resiliency skills,” Trepper says. “We’re building 

self-confidence and encouraging goal setting and positive choice making ...all the ingredients that go into 

preventing young people from getting into a variety of issues, whether it’s opioids or other substances.” 
Arts Strategies for Addressing the Opioid Crisis: Examining the Evidence 21

Research Question 3. What is the evidence on the role of the arts in the treatment of 

SUD, including OUD?

The search process resulted in 36 studies on the topic of SUD treatment. 

Study Characteristics

Most SUD treatment studies were conducted in the United States and evaluated a group music therapy intervention 

that treated participants at inpatient treatment centers. Music therapy sessions often involved lyric analysis, in 

which participants listened to a song and responded to questions from the music therapist about the song lyrics 

(e.g., “Line 14 reads: ‘It took away my pain say please.’ What are some ways to manage and cope with emotional and 

physical pain?”77).

Songwriting was another music therapy intervention studied in the articles included in the literature review. During 

songwriting, the music therapist encouraged dialogue by having participants compose song lyrics that relate to 

clinical objectives (e.g., writing a song about feelings of shame, guilt, and pride).78 Exhibit 7 summarizes study 

characteristics. 

Exhibit 7. Selected Characteristics of Substance Use Disorder Treatment Studies (n = 36)

Characteristic Description Number Percentage Notes

Location

United States 23 64

International 13 36 Common countries: United Kingdom (n = 2); 

Canada (n = 2)

Art form

Music 30 83

Other 6 17 Other art forms: literature (n = 1); psychodrama 

(n = 1); theater (n = 1); cinema (n = 1); other (n = 2)

Participation

Active 34 94 Common activities: lyric analysis (n = 8); 

songwriting (n = 5); drumming (n = 2)

Passive 4 11 Activities: music listening (n = 3); cinema (n = 1)

Program 

format Group 33 92 Common activities: group music therapy (n = 23)

Target 

population

Inpatient 24 67 Includes detox and/or residential treatment

Outpatient 10 28

Court-mandated 

treatment 4 11

Primary drug

Not specified SUD 

or polydrug 17 47

Alcohol 11 31

Opioid 5 14

Note: Characteristics are not mutually exclusive. 
22 National Endowment for the Arts | arts.gov

Methodological Quality 

Among the 18 studies using an RCT design, all missed the MMAT design criterion of blinding outcome assessors 

to the provided intervention. Because SUD treatment outcomes are typically measured through self-report, the 

participant is often the outcome assessor. And because participants typically know whether they received an art 

intervention, they are often not blinded to the intervention. If this item is excluded from the MMAT, 13 RCTs (72 

percent) met all quality criteria. Second to blinding, the most frequently missed criteria were if randomization was 

appropriately performed and if groups were comparable at baseline. Exhibit 8 provides an overview of MMAT results. 

Exhibit 8. Overview of Mixed Methods Appraisal Tool Results for Substance Use Disorder 

Treatment Studies (n = 36)

MMAT category Number Percentage Percentage meeting all quality 

criteria for study design

Qualitative 2 6 50

Quantitative randomized controlled trials 18 50 0

Quantitative nonrandomized 9 25 45

Quantitative descriptive 2 6 50

Mixed methods 5 14 80

Note: By asking participants to self-report outcomes, all RCTs missed the design criterion of blinding outcome assessors to the provided 

intervention.

Study Outcomes

Studies most commonly measured outcomes related to mental health/well-being, such as depression, anxiety, anger, 

sadness, and guilt (see Exhibit 9). Of the 16 studies that fall into this category, eight (53 percent) reported statistically 

significant positive effects. Seven studies of music therapy, for instance, reported significant improvements in 

depression, anxiety, mood, and/or stress reduction.79, 80, 81, 82, 83, 84, 85 Results for other art forms were less promising. 

One study, for example, investigated whether producing art (e.g., drawing, painting) or viewing art (e.g., sorting 

classical art prints) could reduce negative mood and anxiety for adults with SUD (n = 28). Although results indicated 

that negative mood and anxiety did decrease for the art production group, the reduction stemmed from time elapsed 

and not the intervention itself.86

Six music therapy studies measured outcomes related to treatment readiness and motivation, with four (67 percent) 

reporting statistically significant positive effects. A study of a lyric analysis intervention in a detoxification unit found 

that compared with participants in the control condition (n = 53), participants in the treatment condition (n = 51) had 

significantly higher problem recognition, desire for help, treatment readiness, and total motivation scores.87

Of the five studies that measured craving, three (60 percent; two music therapy, one music listening) reported 

statistically significant positive effects. One music listening study found that a combination of systematic 

desensitization and music can reduce craving in response to external cues more than standard treatment alone. 

Similar effects were observed whether participants listened to live music improvised on Tibetan bowls or relaxing 

music played on individual devices.88

Of the five studies (two music therapy, one drumming, one narrative therapy, one theater) that measured abstinence 

or drug use, all reported successful outcomes, but sample sizes were small and none were designed to test statistical 
Arts Strategies for Addressing the Opioid Crisis: Examining the Evidence 23

significance. Upon completion of a 12-week drumming program for American Indians/Alaska Natives with histories 

of SUD, participants (n = 5) reported continued sobriety or reductions in drug and/or alcohol use, but no follow-up 

was conducted.89 A study of narrative therapy with adults aged 55–70 with addiction (n = 12) found that participants 

were able to reduce or halt their substance misuse over the course of an eight-week program, but no follow-up was 

conducted.90

Of the four studies that measured participant engagement/retention (one music therapy, one drumming, one cinema, 

one theater), three reported successful outcomes. None were designed to test statistical significance, however, 

because of small sample sizes. A seven-week trial of music therapy as a means of increasing engagement in an SUD 

treatment group found that participants (n = 24) were highly motivated to participate in group music sessions and 

enjoyed the sessions. Further analyses found that music therapy engaged participants regardless of their age group 

(under age 25 versus over age 25) or substance used (alcohol versus other drugs).91

Exhibit 9. Selected Outcomes of Substance Use Disorder Treatment Studies (n = 36)

Outcome

Measured Statistically significant 

positive effect Notes

Number Percentage Number Percentage

Mental health/well-being 15 42 8 53

Includes depression, 

anxiety, anger, sadness, 

guilt, joy, hope, etc. 

Readiness to change/

motivation 6 17 4 67

Includes readiness 

to change, treatment 

readiness, and motivation

Craving 5 14 3 60

Abstinence/drug use 5 14 0 0

Engagement/retention 4 11 0 0

Working alliance 3 8 2 67

Other 6 17 2 33

Includes emotional 

intelligence (n = 1), falling 

asleep (n = 1), locus of control 

(n = 1), self-concept (n = 

1), self-efficacy (n = 1), and 

sharing of emotions (n = 1)

Note: Outcomes are not mutually exclusive; many studies measured multiple outcomes. 
24 National Endowment for the Arts | arts.gov

Page 

intentionally 

blank
Arts Strategies for Addressing the Opioid Crisis: Examining the Evidence 25

Program Scan

A program scan was conducted to describe and highlight a range of programs that use the arts to address pain 

management or SUD prevention or treatment. This chapter summarizes key findings by research question, presents 

methods used in the program scan, and describes detailed results. It then presents summary profiles of the eight 

arts-based programs selected for inclusion in this report. 

Overview of Key Findings 

This section presents key findings by research question. 

Research Question 1. What is the evidence on the role of the arts in pain 

management?

• Two of the four pain management programs included in the program scan reported statistically significant 

positive findings related to pain reduction.

• Arts-based programs target isolation and stigma among individuals with pain.

Research Question 2. What is the evidence on the role of the arts in the prevention 

of SUD, including OUD?

• Arts-based prevention programs included in the program scan do not measure or report outcomes related 

to the prevention of SUD.

Research Question 3. What is the evidence on the role of the arts in the treatment of 

SUD, including OUD?

• Three programs meeting inclusion criteria for the program scan address SUD in some manner, primarily 

through serving individuals with co-occurring SUD and other physical and mental health conditions.

• Arts-based programs from the program scan address social aspects of SUD, including improving community 

awareness of SUD and reducing stigma to promote resilience and recovery. 

Methods

An initial list of candidate programs was generated through a search of electronic resources (i.e., federal agency 

websites, publication databases, and website search engines) using search terms such as “art therapy,” “art 

education,” “pain management,” “SUD,” and “OUD.” The National Endowment for the Arts and technical working 

group (TWG)i members recommended additional programs for inclusion. These steps produced 50 program scan 

candidates.j Detailed methods can be found in appendix D. 

i James Bell Associates convened a technical working group to help guide the review and/or identify programs and review key deliverables

See the acknowledgments section for a list of TWG members.

j The Arts Endowment limited the number of program scan candidates to no more than nine to ensure compliance with the Office o

Management and Budget regulations regarding the Paperwork Reduction Act.
26 National Endowment for the Arts | arts.gov

To be included in the scan, programs had to meet the following criteria:

1. The program was based on the arts or had prominent components that include the arts as reflected by 

explicit use of keywords in the program’s title/name or published description;

2. The program centered on managing pain or preventing or treating SUD as reflected by explicit use of 

keywords in the program title/name or published description;

3. The program was active or recently implemented (i.e., within the past five years);

4. Evidence of program outcomes was available; and

5. The information needed to determine fit with eligibility criteria was publicly available. 

Of the 50 programs considered, eight met the inclusion criteria (see Exhibit 10). Publicly available information 

for those programs was reviewed and abstracted. Program directors were contacted to ensure accuracy of the 

abstracted information and to learn more about the program components. Program profiles compiled from the 

information collected and confirmed through this process can be found at the end of this chapter. A list of programs 

excluded from the scan can be found in appendix E. 

The programs in the scan are not intended to be examples of evidenced-based interventions. Instead, they are meant 

to illustrate a variety of interesting programs that use the arts to address pain management or SUD prevention or 

treatment. All programs included in the scan had some evidence related to program outcomes.k

 However, the scan 

did not review or assess the type or quality of the supporting methodological designs or review the programs against 

any evidence-based standards. 

k Only one article from the program scan met the criteria for inclusion in the literature review: Ian J. Koebner et al., “The Art of Analgesia: 

Pilot Study of Art Museum Tours to Decrease Pain and Social Disconnection among Individuals with Chronic Pain,” Pain Medicine 20, no. 4 (2018): 

681–91.
Arts Strategies for Addressing the Opioid Crisis: Examining the Evidence 27

Exhibit 10. Programs Included in Scan

Program Location Description Primary art 

form(s) 

Relevant 

focus area(s)

Art Rx Sacramento, 

California

Offers free guided gallery tours for individuals 

living with pain and their families and 

caregivers. https://health.ucdavis.edu/pain/

acupuncture/CrockerArtRx.html

Visual art Pain 

management 

Cleveland 

Clinic Arts 

and Medicine 

Institute

Cleveland, Ohio

Integrates visual arts, music, performing 

arts, and research to promote healing and to 

enhance the lives of patients, families, visitors, 

and employees. https://my.clevelandclinic.org/

departments/arts-medicine

Visual art and 

music

Pain 

management 

M3 (Movement 

+ Mentorship = 

Metamorphosis)

Albuquerque, 

New Mexico

Involves daily dance classes offered as part of 

the high school curriculum onsite at the state’s 

juvenile detention facility. Students receive 

academic credit and learn literacy, math, 

science, and conflict resolution through dance 

to promote positive youth development and 

reduce juvenile incarceration.

https://keshetarts.org/dance/social-justicethrough-dance/#M3

Dance SUD prevention

Moving in the 

Spirit

Atlanta, 

Georgia

Uses dance to teach young people social, 

emotional, and cognitive skills needed to thrive 

and avoid risk behaviors, including substance use. 

http://www.movinginthespirit.org/about-us/

Dance SUD prevention

Porch Light Philadelphia, 

Pennsylvania

Fosters health and wellness by providing 

opportunities for city residents, including those 

with SUD, to contribute to the production of 

public art murals. https://www.muralarts.org/

program/porch-light/

Visual art SUD treatment

Prodigy Cultural 

Arts Program Tampa, Florida

Uses visual and performing arts to help 

young people develop life skills such as 

communication, leadership, anger management, 

career aspirations, and goal-setting to develop 

lifelong positive habits. http://www.uacdc.org/

index.php/about-prodigy

Visual and

performing arts SUD prevention 

Rural Veterans 

TeleRehabilitation 

Initiative Creative 

Arts Therapy 

Project 

Gainesville, 

Florida

Provides creative arts therapies to veterans with 

various health and mental health conditions, 

often with co-occurring SUD, who may be 

isolated in rural areas. Participants engage 

with board-certified creative arts therapists 

via clinical video telehealth. https://blog.

americansforthearts.org/2019/05/15/helpingveterans-build-connections-between-creativearts-therapy-programs-and-their-local-arts

Visual art and 

music

Pain 

management 

and SUD 

treatment 

Semper Sound San Diego, 

California

Provides music therapy to military service 

members and veterans dealing with 

posttraumatic stress disorder, traumatic 

brain injury, and/or substance abuse. https://

resoundingjoyinc.org/semper-sound/

Music 

Pain 

management 

and SUD 

treatment
28 National Endowment for the Arts | arts.gov

Results

This section presents results by research question. 

Research Question 1. What is the evidence on the role of the arts in pain 

management?

Four programs that use the arts to treat and manage pain met criteria for inclusion in the program scan. 

Program Characteristics

Three of the four pain management programs implement music or visual arts therapies delivered by certified 

therapists as their primary intervention(s). Two of those three programs also offer nontherapy arts activity 

components, such as viewing visual art or listening to music performances, in group or community settings. Group 

delivery facilitates the programs’ goals of addressing isolation, social disconnection, and stigma associated with 

the experience of pain. For example, Art Rx emphasizes the importance of participants having positive experiences 

outside of medical or caregiving settings. 

Populations served include veterans with traumatic brain injuries, posttraumatic stress disorder, health conditions, 

or SUD; individuals receiving inpatient or outpatient care in hospital settings; and individuals living with chronic pain. 

All four programs include options to engage families and caregivers. Exhibit 11 summarizes program characteristics.

Exhibit 11. Selected Characteristics of Pain Management Programs (n = 4)

Characteristic Description Art Rx

Cleveland Clinic 

Arts and Medicine 

Institute

RVTRI CAT Semper 

Sound

Setting 

Urban

Rural 

Scope 

One location 

Multiple locations 

Art form(s)

Art activities

Visual art therapy 

Music therapy 

Program format

Individual 

Group 

Another common program element is partnership between the arts and health communities. RVTRI CAT is funded, 

in part, by the U.S. Department of Veterans Affairs (VA) Office of Rural Health and encourages partnership between 

veterans and community artists and arts programs. Semper Sound has also forged a partnership with the VA. Both 

programs ensure veterans’ access to visual art and music therapy rehabilitation services. Services are provided at VA 

hospitals and clinics, on military bases, and remotely. 
Arts Strategies for Addressing the Opioid Crisis: Examining the Evidence 29

Improving access to prevention, treatment, and recovery support services is one potential strategy that arts-based 

interventions can use to support individuals at risk for OUD (see Exhibit 12). 

Exhibit 12. Rural Veterans TeleRehabilitation Initiative Creative Arts Therapy

The RVTRI CAT project delivers virtual art, dance/movement, and music therapy to participants facing 

traumatic brain injuries, posttraumatic stress disorder, chronic pain, SUD, and other health issues. 

Participants include service members and veterans in northern Florida and southern Georgia with limited 

access to rehabilitation services. 

Participants use two-way video to attend weekly, one-on-one sessions with registered and board-certified 

creative arts therapists. Using arts supplies and instruments delivered by the project, participants engage in 

activities such as drumming, painting, drawing, and creative writing.

Research on the RVTRI CAT project has illustrated veterans’ progress in areas such as coping strategies, 

mindfulness, positive self-image, awareness of emotions, and nonpharmacological pain management. 

“Veterans [say they are] more comfortable talking about things truthfully from their own homes. They don’t 

worry about getting tearful or upset and then having to walk out of the VA hospital,” says RVTRI CAT art 

therapist Heather Spooner.

RVTRI CAT is recognized by the VA as an Enterprise Wide Initiative, championing the expansion of 

telerehabilitation services to rural veterans. The initiative’s creative arts therapies project continues to 

expand nationally with support from the VA’s Office of Rural Health and the National Endowment for the 

Arts (Creative Forces). 

Source: Heather Spooner et al., “Using Distance Technology to Deliver the Creative Arts Therapies to Veterans: Case Studies in Art, 

Dance/Movement and Music Therapy,” The Arts in Psychotherapy 62 (2019): 12–18.

Program Outcomes

All four programs reported positive findings related to pain reduction (see Exhibit 13), and two of the four 

program findings were statistically significant.92, 93 For example, the Cleveland Clinic Arts and Medicine Institute 

demonstrated that individuals with cancer who underwent autologous stem cell transplantation (i.e., a bone marrow 

transfusion procedure) and received music therapy used significantly less narcotic pain medication than those who 

did not receive the intervention.94

Two music therapy programs reported outcomes on mental health symptoms such as anxiety, stress, and depression. 

The Cleveland Clinic Arts and Medicine Institute found that participants experienced statistically significant 

reductions in anxiety and depression and improvements in mood, among other outcomes, after participating in music 

therapy sessions at the hospital.95 Similarly, ongoing evaluation of participants in the Semper Sound music therapy 

program showed improvements on pre-/posttherapy session measures of pain, anxiety, stress, and depression, but 

significance testing was not conducted.l

l Unpublished findings from an internal evaluation repor
30 National Endowment for the Arts | arts.gov

Three programs assessed the influence of arts activities on outcomes related to participants’ sense of community, 

including reduced feelings of isolation. For example, Art Rx participants reported decreased feelings of social 

disconnection after attending gallery tours.96

Exhibit 13. Selected Outcomes of Pain Management Programs (n = 4)

Measured outcome Art Rx Cleveland Clinic Arts 

and Medicine Institute

RVTRI 

CAT

Semper 

Sound

Pain reduction/management i ii iii

Dosage/use of narcotic pain medication iv

Sense of community, including reduced feelings 

of isolation and stigma i

Mental health symptoms, including mood, 

anxiety, stress, and depression ii

Sources: i Ian J. Koebner et al., “The Art of Analgesia: A Pilot Study of Art Museum Tours to Decrease Pain and Social Disconnection among 

Individuals with Chronic Pain,” Pain Medicine 20, no. 4 (2018): 681–91; ii Debbie Bates et al., “Music Therapy for Symptom Management 

after Autologous Stem Cell Transplantation: Results from a Randomized Study,” Biology of Blood and Marrow Transplantation 23, no. 9 (2017): 

1567–72.; iii Heather Spooner et al., “Using Distance Technology to Deliver the Creative Arts Therapies to Veterans: Case Studies in Art, Dance/

Movement and Music Therapy,” The Arts in Psychotherapy 62 (2019): 12–18; iv Debbie Bates et al., “Music Therapy for Symptom Management after 

Autologous Stem Cell Transplantation: Results from a Randomized Study,” Biology of Blood & Marrow Transplantation 23, vol. 9 (2017): 1567–72, 

doi:10.1016/j.bbmt.2017.05.015.

Targeting the psychological and social aspects of pain may be one potential strategy for arts-based programs to 

support individuals at risk for OUD (see Exhibit 14). 

Exhibit 14. Art Rx

Art Rx aims to ease the burden of chronic pain through art appreciation and social engagement. Program 

docents lead participants on tours of the Crocker Art Museum in Sacramento, California, and facilitate 

discussions on the experience—how they feel looking at a particular piece of art—rather than the art object 

itself. “It’s about connecting to other people and to the myriad aspects of the self that are not identified with 

the pain,” says director Ian Koebner. 

Art Rx engages health care practitioners in conversations about the value of the arts in pain management 

and partners with them to help support patients tapering off prescription opioids. The program also seeks 

to reduce the isolation of living with chronic pain by encouraging participants to bring guests on the tour, 

allowing them to assume the role of host with friends, families, and caregivers in a nonmedical setting. 

Research on Art Rx has shown decreased feelings of social disconnection and pain unpleasantness among 

participants, who describe the program as a positive experience.
Arts Strategies for Addressing the Opioid Crisis: Examining the Evidence 31

Research Question 2. What is the evidence on the role of the arts in the prevention 

of SUD, including OUD?

Three programs that use the arts to prevent SUD met inclusion criteria for the program scan. 

Program Characteristics

All three prevention programs target youth, with M3 (Movement + Mentorship = Metamorphosis) serving 

incarcerated and paroled youth, and the other two programs serving youth in the community. All the programs 

provide dance classes. The Prodigy Cultural Arts Program offers additional art forms, such as painting, drawing, 

photography, sculpture, and music/orchestra. 

Another common element is the infusion of youth development theory and practice into arts programming. The 

phases of Moving in the Spirit’s dance program, for example, align with key youth development protective factors, 

including positive self-image. The Prodigy Cultural Arts Program ensures that staff artists are as equally skilled and 

trained in youth development practices as in the arts. Mentorship and lasting, long-term connections between staff 

artists and students are central elements of Keshet Dance Company’s M3 program. Program characteristics are 

summarized in Exhibit 15. 

Exhibit 15. Selected Characteristics of Substance Use Disorder Prevention Programs (n = 3) 

Characteristic Description M3 Moving in 

the Spirit

Prodigy Cultural 

Arts Program

Setting 

Urban

Rural 

Scope 

One location 

Multiple locations

Art form

Art activities

Dance 

Visual arts 

Program format

Individual 

Group 

Program Outcomes

Two of the three prevention programs do not measure substance use or substance use–related outcomes. However, 

they do assess important risk and protective factors related to SUD (see Exhibit 16). Academic achievements and 

behaviors were the most commonly measured outcomes. M3 found a 28 percent improvement in math, literacy, 

and science skills from semester to semester, on average, for students taking daily dance classes as part of the high 
32 National Endowment for the Arts | arts.gov

school curriculum at the state juvenile detention facility.m Significance testing was not conducted. Research on the 

Prodigy Cultural Arts Program has shown a positive influence on anxiety, withdrawal/depression, internalizing 

behaviors, aggressive behaviors, externalizing behaviors, social problems, and attention problems among youth 

served by the program.97

Two of the programs also assess important protective factors related to SUD. Third-year Moving in the Spirit 

participants were shown to score statistically significantly higher than first- and second-year participants on 

assessments of positive self-image. Program evaluations also revealed improvements in participants’ confidence, 

empathy, resilience, and sense of belonging, among other factors.n

Moving in the Spirit was the only program to report on outcomes related to substance use. In the most recent 

program year, 97 percent of students indicated that the program helped them better avoid drug and gang activity. 

“Students are always responding positively on how they’re able to become more involved in positive activities 

instead of using drugs,” says Charné Furcron, director of education.

Exhibit 16. Selected Outcomes of Substance Use Disorder Prevention Programs (n = 3)

Measured outcome M3 Moving in 

the Spirit

Prodigy Cultural 

Arts Program

Mental health symptoms, including mood, anxiety, stress, and 

depression i,ii

Behavioral dysregulation, including aggressive behaviors and 

conflict i,ii

Protective factors such as positive self-image iii

Academic achievements

Juvenile justice involvement and recidivism

Substance use 

Sources: i Lisa Rapp-Paglicci, Chris Stewart, and William Rowe, “Improving Outcomes for At-Risk Youth: Findings from the Prodigy Cultural Arts 

Program,” Journal of Evidence-Based Social Work 9, no. 5 (2012): 512–23; ii Tina Maschi et al., “An Evaluation of a Cultural Arts Program for Youth in 

a Juvenile Justice Program: Technical Report” (working paper, National Endowment for the Arts, New York, NY, 2013); iii Leon Rodgers and Charné 

Furcron, “The Dynamic Interface between Neuromaturation, Risky Behavior, Creative Dance Movement, and Youth Development Programming,” 

American Journal of Dance Therapy 38, no. 1 (2016): 3–20.

Research Question 3. What is the evidence on the role of the arts in the treatment of 

SUD, including OUD?

None of the programs included in the scan self-identified as an SUD treatment program; however, three of the 

eight programs address SUD treatment in some manner. Co-occurring SUD was reported as prevalent among the 

populations served by Porch Light, RVTRI CAT, and Semper Sound. Participants had often experienced traumatic 

brain injury, posttraumatic stress disorder, or other physical and mental health conditions. 

m Findings from unpublished evaluation reports

n Findings from unpublished evaluation reports
Arts Strategies for Addressing the Opioid Crisis: Examining the Evidence 33

Porch Light creates murals focused on mental health, substance use, and other community issues to enhance 

resilience and recovery among individuals and to reduce social stigma and encourage empathy within the community. 

RVTRI CAT and Semper Sound provide visual art therapies, music therapies, and other arts activities to veterans and 

military service members. Therapists and participants co-develop treatment plans based on participants’ goals and 

areas of need, including SUD treatment. Exhibit 17 summarizes selected program characteristics. 

Exhibit 17. Selected Characteristics of Substance Use Disorder Treatment Programs (n = 3)

Characteristic Description Porch Light RVTRI CAT Semper Sound

Setting 

Urban

Rural 

Scope Multiple locations 

Art form

Art activities

Visual art therapy

Music therapy 

Program format

Individual 

Group 

Program Outcomes

The treatment programs identified in the scan have not assessed substance abstinence or use. However, the 

programs shared anecdotal successes related to SUD treatment. For example, Cory Woodrow, Semper Sound’s 

director and music therapist, described a common refrain among clients who realized music can help them focus on 

recovery: “[A client will say], ‘This is the first time I didn’t think about alcohol. This is the first time I didn’t think about 

substance use.’”

Mental health symptoms and behaviors such as aggression were the most commonly studied outcomes. Programs 

also assessed their influence on building a sense of community (see Exhibit 18). 

Exhibit 18. Selected Outcomes for Treatment Programs (n = 3)

Measured outcome Porch Light RVTRI CAT Semper Sound

Mental health symptoms, including mood, anxiety, 

stress, and depression i

Sense of community

Stigma associated with SUD

Behavioral outcomes such as aggression, anger 

management, and awareness of emotion i

Source: i Heather Spooner et al., “Using Distance Technology to Deliver the Creative Arts Therapies to Veterans: Case Studies in Art, Dance/

Movement and Music Therapy,” The Arts in Psychotherapy 62 (2019): 12–18.
34 National Endowment for the Arts | arts.gov

Program Profiles 

This section presents summary profiles of the eight arts-based programs selected for inclusion in this report. Profiles 

are listed in alphabetical order by title of program. Descriptive details include the following:

• Background (e.g., year initiated/funded, locations, level/scope)

• Key stakeholders (e.g., implementing agencies, partnerships)

• Target populations

• Focus areas

• Core components and specific interventions

• Intended goals/outcomes

• Evidence/evaluation

• Program website 

Art Rx

Program 

element Details

Background 

Year initiated/funded: October 2014

Location(s): Sacramento, California

Level/scope (e.g., state, county, community): Implemented locally, but open to anyone who 

preregisters for an Art Rx gallery tour 

Key 

stakeholders

Funders: California Arts Council (Research in the Arts Grant); National Center for Advancing 

Translational Sciences, National Institutes of Health, through grant number UL1 TR001860 and 

linked award KL2 TR001859; National Endowment for the Arts (Artworks) 

Lead agency/implementer: Integrative Pain Management Program within the Department of 

Anesthesiology and Pain Medicine at the University of California Davis 

Partner(s): Crocker Art Museum 

Target 

population(s)

• Any individuals self-identifying as having chronic pain as well as their families and 

caregivers

• Participants self-register for gallery tours

Focus area(s)

• Pain management (chronic pain) 

• Arts programming (visual arts)

• Art museum and public health partnerships

Core 

components 

and specific 

interventions

• Free, docent-facilitated, one-hour gallery tours 

• Offered bimonthly at the Crocker Art Museum

• Guided by a “slow art” model, tours concentrate on dialogue around two art objects 

preselected by the Art Rx museum docents, with the intent of focusing on quality 

interactions with art objects rather than on the quantity of objects viewed.

• Emphasis is placed on the viewers’ experience rather than the viewed objects (e.g., How 

does the viewer feel?).
Arts Strategies for Addressing the Opioid Crisis: Examining the Evidence 35

Program 

element Details

Intended goals/

outcomes

• To encourage positive experiences that reduce the burden of chronic pain and caregiver 

stress 

• To address isolation and social disconnection associated with chronic pain

• To demonstrate the feasibility and benefits of partnerships between academic health 

centers and major art museums

Evidence/

evaluation 

Research question(s)/objective(s)

• Study 1: The objective was to examine the feasibility of art museum tours (Art Rx) as an 

intervention for individuals with chronic pain.o

• Study 2: The objective was to describe the design and feasibility of a partnership 

between an art museum and an academic pain center (Art Rx) to address chronic pain.p

Study design(s) and participants 

• Study 1: A single-group quasi-experimental mixed methods study analyzed survey data 

collected pre-Art Rx museum tour, immediately post-tour, and at three weeks post-tour 

(n = 54). In addition, 14 individuals (25 percent of study participants) were purposively 

sampled for semi-structured interviews. 

• Study 2: A qualitative descriptive study comprising key stakeholder interviews with 

participating healthcare providers and museum staff 

Select findings 

• Study 1: The intervention was found to be feasible. Of study participants, 57 percent 

reported pain relief during their tour, with an average pain relief of 47 percent on a scale 

of 0 to 100 percent. 

• Study 1: Study participants also reported statistically significant decreased feelings of 

social disconnection and pain unpleasantness pre- to post-tour.

• Study 1: Participants who were interviewed indicated Art Rx was a positive and inclusive 

experience, with potential lasting benefit. For example, one participant is reported 

as having framed his experience as “building a skill” to use art appreciation and social 

engagement as analgesia. 

• Study 2: Results from interviews indicate both museum and healthcare providers 

view Art Rx as an innovative intervention, perceived as facilitating social connection, 

mitigating isolation, creating opportunities for learning, and offering a meaningful 

distraction from pain for individuals with chronic pain. 

Website https://health.ucdavis.edu/pain/acupuncture/CrockerArtRx.html

o For more information see Koebner et al., “The Art of Analgesia

p For more information see Ian. J. Koebner et al., “Curating Care: The Design and Feasibility of a Partnership between an Art Museum and a

Academic Pain Center,” Curator: The Museum Journal 61, no. 3 (2018): 415–29.
36 National Endowment for the Arts | arts.gov

Cleveland Clinic Arts and Medicine Institute

Program 

element Details

Background 

Year initiated/funded: 2008 

Location(s): Cleveland Clinic is headquartered in Cleveland, Ohio, with enterprise locations across the 

United States and internationally. 

Level/scope (e.g., state, county, community): The Arts and Medicine Institute implements programming 

throughout the Cleveland Clinic enterprise, in multiple units on the main campus and at regional hospitals 

including Cleveland Clinic enterprise locations in Florida and Nevada. 

Key 

stakeholders

Funders: Funded internally through the Cleveland Clinic as well as by donations and grants 

Lead agency/implementer: Cleveland Clinic 

Partner(s): Multiple community collaborators, including the Alzheimer’s Association, Beck Center for 

the Arts, Cleveland Arts Prize, Cleveland Museum of Art, Credo, Dancing Wheels Company and School, 

Epilepsy Association, Museum of Contemporary Art Cleveland, and Roots of American Music, among 

others

Target 

population(s)

• Individuals of all ages receiving inpatient or outpatient care at a participating Cleveland Clinic 

location as well as their families, caregivers, medical staff, and visitors 

• For example, participating patients may be receiving care in the Children’s, Heart and Vascular 

Institute units, Cancer Institute, transplant special care units, behavioral health units, and 

rehabilitation services, among others.

• The program also targets the broader community to build connections between the arts, health, 

and medicine.

Focus area(s)

• Pain management 

• Creative arts therapies (art therapy and music therapy)

• Arts programming (visual and performing arts)

• Research and community building around the arts and healing

Core 

components 

and specific 

interventions

• Visual art and music therapy provided by board-certified therapists is offered as a complimentary 

service in inpatient and outpatient units and in various community programs. 

• Therapies are received based on referrals as well as on request.

• Programs and groups are offered in select locations. 

• Therapy materials and interventions are chosen to correspond with the interests, physical 

condition, and goals of individual patients.

• The Performing Arts Program and Visual Art Collections enhance the environment and Cleveland 

Clinic experience for patients and caregivers. Listeners are provided an opportunity to engage in 

high-quality performances by local musicians, with special events featuring dancers, ensembles, 

and local schools and arts organizations. Visual arts works are curated in public spaces. 

• Through a series of lectures, workshops, and presentations, people are given the opportunity to 

learn about the arts and the benefits of the arts.

Intended 

goals/

outcomes

• To enhance patients’ experience at Cleveland Clinic through the arts

• To assist with emotional and physical healing and growth 

• To build community around the arts, health, and medicine
Arts Strategies for Addressing the Opioid Crisis: Examining the Evidence 37

Program 

element Details

Evidence/

evaluation 

Several studies have been completed in association with Cleveland Clinic’s Arts and Medicine Institute. q

Four are highlighted below.

Research question(s)/objective(s)

• Study 1: To examine the impact of art therapy sessions at the bedsider

• Study 2: To understand the impact of music therapy sessions; identify common music therapy 

goals and interventions and assess their effect; and investigate the effects of gender, age, and type 

of cancer on symptoms in patients who experienced music therapy s

• Study 3: To understand the impact of music therapy on post-elective orthopedic surgery patients’ 

pain, mood, anxiety, nausea, use of narcotics and antiemetics, and length of stay t

• Study 4: To determine the effect of music therapy among patients with lymphoma or multiple 

myeloma undergoing autologous stem cell transplantation (i.e., bone marrow transplantation) u

Study design(s) and participants

• Study 1: Retrospective chart review of patients who received an art therapy session and had 

documented pre and post ratings of mood, anxiety, and pain

• Study 2: A retrospective study of data collected during music therapy sessions over 12 years. 

Patients scored pain, anxiety, depression, shortness of breath, and mood symptoms before 

and after sessions. Interventions were classified as music-assisted relaxation, music listening, 

verbal/emotional participation, verbal/cognitive participation, vocal participation, and physical 

participation. 

• Study 3: A randomized controlled study with an experimental arm (music therapy sessions) and a 

control arm (standard medical care). Data were obtained for 163 of the 200 randomized patients.

• Study 4: A randomized controlled trial with an experimental arm (interactive music therapy; n = 

37) and a control arm (no music therapy; n = 45) 

Select findings

• Study 1: The results support the hypothesis that mood would be improved, and anxiety and pain 

reduced, after participation in an art therapy session at bedside. Choice of media, age, sex, or 

diagnosis did not significantly affect results. 

• Study 2: There was a positive and statistically and/or clinically significant effect on pain, anxiety, 

depression, shortness of breath, mood, facial expression, and verbalization outcomes from pre- to 

post-music therapy session (n = 293).

• Study 2: Of patients, 96 percent had positive responses to participating in music therapy. Vocal 

and emotional interventions were determined to be the most effective intervention types in 

improving symptoms. Age, gender, and diagnosis had no impact on symptom improvement.

• Study 3: In total, 73 percent of music therapy patients versus 41 percent of control patients 

reported improved pain (p < 0.001). No significant between-group differences in medications or 

length of stay were noted. Greater same-day improvements of pain, emotional status, and nausea 

were noted for patients who received music therapy sessions while hospitalized after elective 

orthopedic surgeries.

• Study 4: Music therapy and control group patients had similar pain scores; however, the patients 

who received music therapy used significantly less narcotic pain medication (median, 24 mg versus 

73 mg; p = 0.038). 

Website https://my.clevelandclinic.org/departments/arts-medicine

q More information on the breadth and depth of research is summarized in the Cleveland Clinic Art and Medicine Institute’s 10-year 

anniversary retrospective newsletter, https://my.clevelandclinic.org/-/scassets/files/org/arts-medicine/newsletter/2018-ami-newsletter.

ashx?la=en.

rFor more information see Tamara A. Shella, “Art Therapy Improves Mood, and Reduces Pain and Anxiety When Offered at Bedside durin

Acute Hospital Treatment,” The Arts in Psychotherapy 57 (2018): 59–64.

sFor more information see Lisa M. Gallagher, Ruth Lagman, and Lisa Rybicki, “Outcomes of Music Therapy Interventions on Sympto

Management in Palliative Medicine Patients,” American Journal of Hospice and Palliative Medicine 35, no. 2 (2018): 250–57.

tFor more information see Lisa M. Gallagher et al., “Impact of Music Therapy on Hospitalized Patients Post Elective Orthopedic Surgery: 

Randomized Controlled Trial,” Orthopaedic Nursing 37, no. 2 (2018): 124–33.

uFor more information see Debbie Bates et al., “Music Therapy for Symptom Management after Autologous Stem Cell Transplantation

Results from a Randomized Study,” Biology of Blood & Marrow Transplantation 23, vol. 9 (2017): 1567–72, doi:10.1016/j.bbmt.2017.05.015.
38 National Endowment for the Arts | arts.gov

M3 (Movement + Mentorship = Metamorphosis)

Program 

element Details

Background 

Year initiated/funded: Keshet Dance Company has been developing its movement and mentorship 

program (M3) since 1996.

Location(s): Albuquerque, New Mexico; expansion of the M3 model nationally through Keshet’s 

Movement for Mercy program and New Mexico Arts & Justice Network (NMAJN). NMAJN is a 

statewide network launched by Keshet and community partners to support system-impacted 

youth within the full juvenile justice continuum via the arts.

Level/scope (e.g., state, county, community): M3 is a statewide program. Through Movement for 

Mercy, the M3 movement-based model has been implemented in five pilot sites and continues to 

expand through NMAJN.

Key 

stakeholders

Funders: Funding for M3 has been provided by the United Way of Central New Mexico, Sheila 

Fortune Foundation, Sandia Foundation Grant, Andrew W. Mellon Foundation, and private 

donors.

Lead agency/implementer: Keshet Dance Company (private, nonprofit organization)

Partner(s): M3 partners include the New Mexico Children, Youth and Families Department; State 

Youth Detention Center; and Camino Nuevo Youth Center. 

Target 

population(s)

• Incarcerated and paroling youth and young adults 

• Keshet reaches approximately 100 incarcerated New Mexico youth per year in the 

introductory and intermediate levels of M3 and approximately ten students per year in 

the advanced level of the program. 

• A broader target population will be served through NMAJN, including new partnerships 

with entities focused on behavioral health and substance use disorder. 

Focus area(s)

• Prevention 

• Education 

• Youth development 

• Dance (art genres will diversify through NMAJN expansion)

Core 

components 

and specific 

interventions

• The M3 program has three stages—introductory, intermediate, and advanced. 

○ During the introductory stage, dance is used to teach math, science, literacy, and 

conflict resolution skills within the high school on site at the State Youth Detention 

Center. The curriculum pairs a style of dance with an academic or social skill topic. 

Each unit uses movement to explore the subject matter.

○ Students completing the introductory classes move into the intermediate stage 

considered “pre-release.” In this phase, programming is customized for each student 

to span the remainder of his or hertheir sentence (ranging from a few weeks to 

multiple years). 

○ During the advanced stage, occurring upon parole/release, Keshet individually 

customizes a new track of programming to support the process of parole and 

reintegration. 

• A critical element of the M3 program is the consistent relationship between artists and 

students. M3 staff artists approach each student as a fellow artist, not as an inmate or 

juvenile delinquent. Emphasis is placed on the longevity of the relationship. 
Arts Strategies for Addressing the Opioid Crisis: Examining the Evidence 39

Program 

element Details

Intended goals/

outcomes

• To teach incarcerated youth self-esteem, confidence, teamwork, and academics through 

dance

• To reduce and eliminate juvenile incarceration and to replace systems of incarceration 

with systems of community mentorship

Evidence/

evaluation 

Peer-reviewed, published studies have not yet been conducted of the M3 program. Keshet 

assesses academic outcomes by semester for participating students as well as occurrences of 

conflict incidences and recidivism rates as compared with nonparticipating youth inmates. These 

findings reflect ongoing averages:

• Participating students demonstrate, on average, a 28 percent improvement rating on 

math, literacy, and science skills from semester to semester.

• On an annual basis, participating students demonstrate, on average, a 20 percent 

reduction in conflicts with other inmates and staff compared with nonparticipating 

inmates. 

• M3 has seen a zero percent recidivism rate for students who complete all levels of the 

program as compared with the 50 percent juvenile recidivism rate within the state of 

New Mexico. 

Website https://keshetarts.org/dance/social-justice-through-dance/#M3
40 National Endowment for the Arts | arts.gov

Moving in the Spirit

Program 

element Details

Background 

Year initiated/funded: Programming began in 1986 as an agency of FCS Urban Ministries; Moving 

in the Spirit became a separate nonprofit in 1996.

Location(s): Atlanta, Georgia 

Level/scope (e.g., state, county, community): Implemented locally, but a student touring company 

provides performances across the country 

Key 

stakeholders

Funders: Friends of Moving in the Spirit and private donors 

Lead agency/implementer: Moving in the Spirit 

Partner(s): Numerous partners, including local Boys & Girls Clubs, recreation centers, shelters and 

support services, schools, and the Rialto Center for Arts at Georgia State University 

Target 

populations(s)

• Children and teens aged 3 to 18 years old, regardless of ability to pay 

• Moving in the Spirit serves over 250 youth annually. 

• On average, youth remain with Moving in the Spirit for seven years.

Focus areas(s)

• Prevention 

• Positive youth development 

• Arts programming (dance)

Core 

components 

and specific 

interventions

• Dance classes include Stepping Stones (open-level offering for youth aged 3 to 18), Men 

in Motion (boys aged 9 to 13), GLOW (Girls Leading Our World) in Motion (girls aged 9 to 

13), Apprentice Corporation intensive training program (youth aged 13 to 18), Student 

Touring Dance Company for advanced students, and summer camps for youth aged 8 to 

13. 

• The curriculum focuses primarily on modern dance and incorporates ballet technique, 

creative movement, and the creation of original choreography. Emphasis is placed on 

nonverbal communication and kinesthetic learning.

• Students have a voice in class and choreography, set personal goals, problem-solve with 

peers, and practice leadership skills. 

• Youth development best practices are integrated into all class structures. For example, 

dance classes have five phases that align with and support the five protective factors 

outlined in the Strengthening Families Protective Factors Framework.v 

Intended goals/

outcomes)

• To help children and teens develop the social, emotional, and cognitive skills they need to 

thrive

• To create opportunities for youth who otherwise lack access to after-school enrichment 

programs, especially those focused on the arts 

vFor more information on the Protective Factors Framework, see the Center for the Study of Social Policy’s website at https://cssp.org/ourwork/projects/protective-factors-framework
Arts Strategies for Addressing the Opioid Crisis: Examining the Evidence 41

Program 

element Details

Evidence/

evaluation 

Research question(s)/objective(s)

• Study 1: Does length of participation in an inner-city youth dance program help young 

people avoid risky behavior and acquire competence in essential life skills?w

• Internal monitoring and evaluation efforts assess key outcomes of interest throughout 

the program year and over time. 

Study design(s) and participants

• A quasi-experimental study was conducted through which the Piers-Harris Children’s 

Self-Concept Scale (Piers-Harris 2), a widely used measure of psychological health, was 

administered to participants for three consecutive years (n = 17).

• To assess key outcomes throughout the program year, Moving in the Spirit uses 

and analyzes data from the Pro-Social Checklist, Piers-Harris 2 Self Concept Test, 

Developmental Assets Profile, and a Modern Dance Technique Assessment. Youth 

feedback is also collected through self-report participant surveys. 

Select findings

• Third-year participants scored significantly higher than first- and second-year 

participants on physical appearance and attributes (corresponding to the program’s 

youth development goal of positive self-image). 

• Ongoing program evaluation has revealed the following: 

○ Youth show significant improvement in youth development goals, including 

confidence, empathy, resilience, conflict management, behavioral and intellectual 

competency, and sense of belonging, as measured by standardized assessments. 

○ In the 2018 program year, students stated that Moving in the Spirit helped them 

improve in avoiding drug and gang activity (97 percent), setting personal goals (98 

percent), expressing anger without violence (99 percent), and working hard in school 

(93 percent).

○ Over the past ten years, 100 percent of Moving in the Spirit participants have 

graduated high school and gone on to college, vocational school, or military careers. 

Website http://www.movinginthespirit.org/

wFor more information, see Leon Rodgers and Charné Furcron, “The Dynamic Interface between Neuromaturation, Risky Behavior, Creativ

Dance Movement, and Youth Development Programming,” American Journal of Dance Therapy 38, no. 1 (2016): 3–20.
42 National Endowment for the Arts | arts.gov

Porch Light 

Program 

element Details

Background 

Year initiated/funded: 2007

Location(s): Philadelphia, Pennsylvania 

Level/scope (e.g., state, county, community): Implemented locally 

Key 

stakeholders

Funders: Private contributions account for 50 percent of the annual expenses. The main funder of the 

program is the City of Philadelphia’s Department of Behavioral Health and Intellectual disAbility Services. 

Lead agency/implementer: City of Philadelphia Mural Arts Program and Mural Arts Advocates in joint 

collaboration with the City of Philadelphia’s Department of Behavioral Health and Intellectual disAbility 

Services 

Partner(s): As of 2017, current partners include Veterans Empowerment Center, New Kensington 

Community Development Corporation, Impact Services Inc., Prevention Point Philadelphia, The Kirkbride 

Center, North Philadelphia Health Systems, Children’s Crisis Treatment Center, New Life Recovery and 

Learning Center, and Einstein Healthcare Network Long-Term Structured Residence, among others.

Target 

population(s) • Persons dealing with behavioral health conditions 

Focus area(s)

• Behavioral health 

• Trauma

• Substance use recovery

• Community

• Refugees and immigrants

• Homelessness 

Core 

components 

and specific 

interventions

• Participatory mural-making by teams of people with and without behavioral health conditions, 

often in distressed neighborhoods, through two-year partnerships with behavioral health 

provider sites

• Three community storefront locations where a variety of arts programming is used to address 

community needs, including immigration, housing, and substance use 

• Year-round workshops, arts programming, community meetings, health forums, and paint days 

offered through provider sites and storefronts

• A central theme to the program’s work is the importance of having a safe and inviting space to 

come home to in the darkness (i.e., a porch light). Hence, the program’s name symbolizes the 

explicit intent to create safe havens throughout the city where people can find shelter from 

mental and emotional challenges.

• Social justice, health equity, and social change through participatory public artmaking 

Intended 

goals/

outcomes

• To improve individuals’ health by increasing access to resources (such as behavioral health 

and social services); reducing personal stigma; and developing skills to enhance resilience and 

recovery (such as social skills, self-expression, esteem building, problem-solving, abstract thinking, 

or skills related to making art)

• To improve the community’s health by promoting community and social inclusion, reducing social 

stigma of behavioral and mental health conditions, improving the neighborhood physical and 

social environments, and promoting community connectedness 

• To improve public health by increasing awareness about mental health and wellness, increasing 

attention to social determinants of health, promoting collective self-efficacy in a neighborhood, 

and using art as a catalyst for individual and social change 
Arts Strategies for Addressing the Opioid Crisis: Examining the Evidence 43

Program 

element Details

Evidence/

evaluation 

Several studies of the Porch Light program have been completed.x

 Four are highlighted below.

Select research question(s)/objective(s)

• Study 1: Can group-based, participatory mural- making improve health outcomes and reduce 

stigma among individuals in treatment for a significant behavioral health condition? y

• Study 2: To identify individual mechanisms of change that result from participating in groupbased, participatory mural- making for individuals in treatment for a significant behavioral health 

condition.z

• Study 3: To describe the impact of a participatory public mural-making process focused on suicide 

that was intended to help community members heal and to stimulate a community mobilization 

initiative to prevent suicide. aa

Study design(s) and participants

• Study 1: A comparative outcome trial was used to compare health outcomes and stigma reported 

by 264 individuals receiving treatment in three pairs of behavioral health clinics matched on key 

characteristics of service recipients.

• Study 2: This study completed in-depth, follow-along qualitative interviews with ten individuals 

who engaged in group-based, participatory mural- making over a six- to 12-month period. 

• Study 3: This qualitative case study used seven brief, first-person accounts to describe the impact 

of this initiative. The accounts were from leaders of three sponsoring agencies, the lead muralist, a 

suicide researcher, and two community members who are suicide survivors.

Select findings

• Study 1: After almost two years, residents living within one mile of more than one newly installed 

mural reported a sustained increase in collective efficacy, including social cohesion and trust 

among neighbors as well as informal neighborhood social control, and a sustained decrease in 

stigma toward individuals with mental health or substance abuse challenges.

• Study 1: Overall comparisons of outcomes did not significantly differ across sites, but when 

attendance and implementation at mural-making clinic sites were taken into account, individuals 

who participated in mural- making reported less stress and reduced behavioral health stigma.

• Study 2: Focusing on two case studies for illustrative purposes, four potential mechanisms of 

change were identified that result from participation: (1) increased friendship, (2) an enhanced 

sense of self, (3) a desire to give back to one’s community, and (4) increased hope for the future.

• Study 3: First-person accounts provided encouraging evidence of individual and community 

healing, social connectedness, and reduced feelings of stigma. The project also demonstrated the 

feasibility of using participatory public art as a basis for mobilizing large and diverse groups of 

community participants in a suicide prevention initiative.

Website https://www.muralarts.org/program/porch-light/

xPublished studies to date have focused on the provider site’s component of Porch Light’s programming. An updated list of publications fo

this project can be found at https://medicine.yale.edu/psychiatry/consultationcenter/. 

y For more information see Jacob K. Tebes et al., Porch Light Program: Final Evaluation Report (New Haven, CT: Yale School of Medicine, 2015)

https://medicine.yale.edu/psychiatry/consultationcenter/Images/Porch_Light_Program_Final_Evaluation_Report_Yale_June_2015_Optimized_

tcm798-218966.pdf.

zFor more information see Nathaniel V. Mohatt et al., “From Recovery-Oriented Care to Public Health: Case Studies of Participatory Public Ar

as a Pathway to Wellness for Persons with Behavioral Health Challenges,” Journal of Psychosocial Rehabilitation and Mental Health 2, no. 1 (2015): 9–18.

aaFor more information see Nathaniel V. Mohatt et al., “A Community’s Response to Suicide through Public Art: Stakeholder Perspective

from the Finding the Light Within Project,” American Journal of Community Psychology 52, no. 1–2 (2013): 197–209.
44 National Endowment for the Arts | arts.gov

Prodigy Cultural Arts Program

Program 

element Details

Background 

Year initiated/funded: 2000

Location(s): Tampa, Florida

Level/scope (e.g., state, county, community): The program is offered in eight counties in west central 

Florida through subcontracted organizations. It has a mobile component, Prodigy Moves!, that 

takes mobile cultural arts classrooms to underserved students in high-risk neighborhoods across 

these counties, including within students’ housing communities and apartment complexes.

Key 

stakeholders

Funders: University Area Community Development Corporation, Department of Juvenile Justice, 

and private donors 

Lead agency/implementer: Prodigy Cultural Arts 

Partner(s): The Orlando Neighborhood Improvement Corporation, The Florida Museum of 

Photographic Arts, the Florida Orchestra, the University Area Community Development 

Corporation, Tampa Housing Authority, Girls Inc., local Boys & Girls Clubs, local YMCA chapters, 

and local schools, among others 

Target 

populations(s)

• Youth aged five5 to 18 years old (the program has a history of servicing at-risk youth and 

youth who have been adjudicated in the juvenile justice system)

• Prodigy has served more than 28,000 youth. 

Focus areas(s)

• Prevention 

• Positive youth development 

• Life skills-–infused cultural arts

• Arts programming (visual and performing arts)

Core 

components 

and specific 

interventions

• Eight-week-long visual and performing arts classes taught by master artists at no cost to 

participants 

• Curriculum and ages served vary by location. Program fidelity is assessed using 

performance measures. 

• Prodigy teaches core self-regulation skills, including anger management, problemsolving, and communication.

• Classes are designed to explore and creatively express thoughts, feelings, and values. 

Each class focuses on a specific life skill (e.g., anger management) and connects it to the 

art.

Intended goals/

outcomes

• Prodigy uses visual and performing arts as a way to help young people develop life skills, 

build self-confidence, and develop lifelong positive habits for future success.
Arts Strategies for Addressing the Opioid Crisis: Examining the Evidence 45

Evidence/

evaluation 

Research question(s)/objective(s)

• Study 1: To evaluate the Prodigy Cultural Arts Program as an early prevention program 

for adjudicated youth ab

• Study 2: To examine the impact of Prodigy on social skills and mental health outcomes ac

Study design(s) and participants

• Study 1: A quasi-experimental pre- and posttest study among 140 adolescents served by 

the program (8 to 18 years old, with a mean age of 16; 53 percent boys and 47 percent 

girls; 77 percent of youth were adjudicated by the state juvenile system). Outcome 

measures included assessments of mental health, social skills, behavioral skills, and 

family functioning.

• Study 2: A wait-listed comparison group design with pre- to post-assessments of mental 

health, social skills, and behavioral measures. Participants included 53 youth in the 

treatment group and 32 in the comparison group, with mean ages of 14.9 and 12.6, 

respectively. 

Select findings

• Study 1: Significant reductions were seen in mental health symptoms (particularly 

for females) and behavioral dysregulation (particularly for males). Specifically, youth 

showed reduction in anxiety, withdrawal/depression, internalized behaviors, aggressive 

behaviors, externalizing behaviors, social problems, and attention problems. Significant 

increases in academic performance and family functioning were also found. ad

• Study 2: Modest effects on social skills and mental health outcomes were reported, 

with more impact on females than males. Overall, program participants showed positive 

trends in reduction of aggressive behavior and behavioral dysregulation, and increased 

social problem-solving. 

• Program monitoring findings demonstrate that 95 percent of youth enrolled do not have 

contact with law enforcement and for those who have committed a minor offense, over 

89 percent do not reoffend.

Website https://www.uacdc.org/index.php/about-prodigy

abFor more information see Lisa Rapp-Paglicci, Chris Stewart, and William Rowe, “Improving Outcomes for At-Risk Youth: Findings from th

Prodigy Cultural Arts Program,” Journal of Evidence-Based Social Work 9, no. 5 (2012): 512–23.

acFor more information see Tina Maschi et al., “An Evaluation of a Cultural Arts Program for Youth in a Juvenile Justice Program: Technica

Report” (working paper, National Endowment for the Arts, New York, NY, 2013), https://www.arts.gov/sites/default/files/Research-Art-WorksFordham1.pdf.

ad  Findings are supported by earlier published evaluations demonstrating similar outcomes for the program. For more information se

Lisa Rapp-Paglicci, Chris Stewart, and William Rowe, “Can a Self-Regulation Skills and Cultural Arts Program Promote Positive Outcomes in 

Mental Health Symptoms and Academic Achievement for At-Risk Youth?,” Journal of Social Service Research 37 (2011): 309–19; and Chris Stewart, 

Lisa Rapp-Paglicci, and William Rowe, “Evaluating the Efficacy of the Prodigy Prevention Program across Urban and Rural Locales,” Child and 

Adolescent Social Work Journal 26 (2009): 65–75.
46 National Endowment for the Arts | arts.gov

Rural Veterans TeleRehabilitation Initiative Creative Arts Therapy (RVTRI CAT) 

Program 

element Details

Background 

Year initiated/funded: The Rural Veterans TeleRehabilitation Initiative (RVTRI) was established within the 

North Florida/South Georgia Veterans Health System in 2009. Art and dance/movement therapy were 

added in 2014 and in 2017 the program began offering music therapy through a partnership with Creative 

Forces: National Endowment for the Arts Military Healing Arts Network.

Location(s): The primary catchment area for the RVTRI CAT project is the territory of the North Florida/

South Georgia Veterans Health System (NF/SG VHS). Three new expansion sites beyond NF/SG VHS are 

being added and are expected to begin operations.

Level/scope (e.g., state, county, community): RVTRI is an Enterprise-Wide Initiative of the Veterans Affairs 

(VA) Office of Rural Health. Current expansion includes three new sites offering creative arts therapy 

services for veterans in Ohio, Indiana, and Mississippi.

Key 

stakeholders

Funders: VA Office of Rural Health, National Endowment for the Arts (Creative Forces), and Americans for 

the Arts

Lead agency/implementer: North Florida/South Georgia Veterans Health System and Rural Veterans 

TeleRehabilitation Initiative 

Partner(s): University of Florida’s Center for Arts in Medicine

Target 

population(s)

• Veterans and some qualifying active duty service members throughout North Florida or South 

Georgia are referred by their VA providers. 

• Referrals are most often made for veterans with traumatic brain injury (TBI), posttraumatic stress 

disorder (PTSD), various physical health conditions, chronic pain, and substance use disorders.

• Participants live an average of 93 miles away from a VA health facility.

Focus area(s)

• Rehabilitation

• Mental health

• Pain management

• Substance abuse treatment

• Creative arts therapies (art therapy, dance/movement therapy, music therapy)

Core 

components 

and specific 

interventions

• RVTRI CAT engages veterans in creative arts therapy sessions with board-certified creative arts

therapists via real-time, two-way video (i.e., clinical video telehealth).

• Participants generally attend an initial visit in person at the NF/SG Veterans System’s Medical 

Center and then receive six to eight weekly individual telehealth sessions. A hybrid of the 

model allows veterans to participate primarily in person, primarily via telehealth, or through a 

combination of delivery methods. 

• Treatment plan goals are developed collaboratively by veterans and their creative arts therapists 

with consideration for the reason for referral and assessment results.

• Assessments include the Formal Elements Art Therapy Scale, World Health Organization Quality 

of Life Scale Brief Version, Positive and Negative Affect Schedule-Expanded Form, and the 

Montreal Cognitive Assessment.
Arts Strategies for Addressing the Opioid Crisis: Examining the Evidence 47

Program 

element Details

Intended 

goals/

outcomes

• To enable access to high-quality rehabilitation services for rural veterans

• To deliver rehabilitation services to rural veterans using encrypted in-home, live-streaming video

• To promote psychological and emotional health among participants, including improved 

interpersonal and communication skills; management of difficult emotions; reduced depression, 

stress, and anxiety; and improved cognition, memory, sensory-motor function, impulse control, 

concentration, and sleep

• To promote autonomy and independence in the assimilation process of active duty to veteran 

status

• To improve participation, activity, and community integration

Evidence/

evaluation 

Research question(s)/objective(s)

• Study 1: To document and describe the RVTRI CAT creative arts therapy practice ae

• Study 2: To illustrate how creative arts therapies telehealth is delivered and how telehealth can 

be applied across different demographics, as well as to demonstrate some of the challenges and 

opportunities for creative arts therapists delivering services via telehealth af

Study design(s)

• Study 1: At the time of the study, the program had received referrals for 113 outpatient veterans, 

of which 69 percent completed an initial evaluation and 78 percent of those completed at least 

one follow-up session. Of therapy sessions, 58 percent took place via telehealth. Program insights 

were drawn from interviews with participating veterans who conducted at least 50 percent of 

their sessions via telehealth.

• Study 2: Three case studies were presented of veterans who received either art therapy, dance/

movement therapy, or music therapy via in-home, synchronous clinical video telehealth.

Select findings

• Study 1: Feedback from program participants suggests RVTRI CAT fills a much-needed gap for 

veterans by providing consistent in-home care between face-to-face visits.

• Study 2: The three case studies demonstrate the potential and feasibility of delivering 

creative arts therapy via telehealth. Case study participants reported making progress toward 

individualized goals, including developing improved coping strategies, increasing mindfulness, 

promoting a more positive self-image, being more aware of emotions, improving pain 

management, and increasing physical mobility. 

• Study 2: When familiarity and comfort are established with technology, it can become a tool 

for veterans who are geographically isolated to address other challenges and barriers in their 

transition to a meaningful and engaged civilian life. One area of significant potential with 

telehealth is the possibility for it to be used as a bridge between clinical care and community 

integration.

Websites 

https://blog.americansforthearts.org/2019/05/15/helping-veterans-build-connections-betweencreative-arts-therapy-programs-and-their-local-arts

https://www.kpbs.org/news/2018/may/09/new-va-telehealth-program-brings-art-therapy-vets-/

aeFor more information see Charles E. Levy et al., “Telehealth-Based Creative Arts Therapy: Transforming Mental Health and Rehabilitatio

Care for Rural Veterans,” The Arts in Psychotherapy 57 (2018): 20–26.

afFor more information see Heather Spooner et al., “Using Distance Technology to Deliver the Creative Arts Therapies to Veterans: Cas

Studies in Art, Dance/Movement and Music Therapy,” The Arts in Psychotherapy 62 (2019): 12–18.
48 National Endowment for the Arts | arts.gov

Semper Sound

Program 

element Details

Background 

Year initiated/funded: Resounding Joy Inc. has been providing supportive music and music therapy 

since 2005. The Semper Sound Military Music Therapy Program was established in 2010. 

Location(s): San Diego, California

Level/scope (e.g., state, county, community): Implemented locally at military bases, veterans’ 

facilities, and the Resounding Joy Music Wellness Center. Semper Sound also operates satellite 

military music therapy services at the Soldiers’ Home in Chelsea, Massachusetts. 

Key 

stakeholders

Funders: Resounding Joy, grants (from foundations and government agencies such as the 

California Arts Council), individual donors, and military/veteran facilities

Lead agency/implementer: Resounding Joy Inc.

Partner(s): Semper Sound partners with a number of local service facilities in the San Diego area, 

including the San Diego Veterans Affairs Medical Center and Naval Medical Center San Diego.

Target 

population(s)

• Military service members and veterans of all ages diagnosed with PTSD, TBI, substance 

abuse, and other stress- and trauma-related physical and psychological conditions

• Semper Sound provides music therapy to hundreds of active, limited duty, and retired 

service members and their families annually.

• The program reaches thousands of community members each year through public 

performances by the Semper Sound Band and other music programming events. 

Focus area(s)

• Service member and veteran rehabilitation

• TBI and PTSD

• Pain management 

• Creative arts therapy (music therapy)

• Community music programming 

Core 

components 

and specific 

interventions

• Identified as a model program by the American Music Therapy Association, Semper 

Sound provides impact through three tiers of services and supports: (1) music therapy 

curriculum, (2) supportive music services, and (3) community music programming. 

• Semper Sound music therapists have additional training in neurologic music therapy, 

which addresses TBI and other relevant diagnoses in the military community. 

• Semper Sound music therapists use a variety of music-based interventions, such as 

interactive music- making, songwriting, therapeutic instrument instruction, lyric 

analysis, guided relaxation music, and improvisation.

• Individual and group sessions focus on clients’ symptom management, creativity, 

achievement of goals, and developing insight into one’s own abilities and personality.

• Semper Sound’s Peer-Support Model encourages music therapy participants and local 

veteran musicians to connect through Semper Sound Band. The band was created 

to ensure continuity from clinic to community, to support military transition and 

reintegration, and to reinforce therapeutic goals.

• In 2018, Resounding Joy and other nonprofits secured a grant to host Pop-Up 

Community Creative Arts Cafés in various locations across San Diego County. The cafés 

are designed to bridge the gap between residents and the area’s military community, 

introduce service members to an array of art, and provide information to military 

personnel about services and programs available to them.
Arts Strategies for Addressing the Opioid Crisis: Examining the Evidence 49

Program 

element Details

Intended goals/

outcomes

• Clients learn to use music as a coping skill to manage anger, anxiety, and physical/

emotional pain from PTSD, TBI, and other diagnoses.

• Clients increase their awareness and insight of self and others.

• Clients gain communication skills.

Evidence/

evaluation 

Published research on the Semper Sound program has not yet been conducted. Resounding Joy 

uses per-session outcomes and reviews patient and staff surveys and testimonials to internally 

evaluate the success of the Semper Sound program. 

• Between January and September 2019, program participants showed improvements 

in pain, anxiety/stress, anger, and depression outcomes from pre-session to postsession. Specifically, clients reported an average decrease in pain of 17.02 percent, a 

40.26 percent improvement in anxiety/stress, a 38.40 percent reduction in depression, 

and a 55.21 percent improvement in anger. During the period, Semper Sound had 511 

unduplicated contacts with service members/veterans.

• Veterans share positive testimonials of their experience receiving music therapy 

sessions and participating in the Semper Sound Band, including that the programming 

helped them cope with anger management issues and anxiety, helped them feel bonded 

to others and have a sense of community, and improved their physical mobility through 

activities such as learning to play the piano.

Website https://resoundingjoyinc.org/semper-sound/
50 National Endowment for the Arts | arts.gov

Page 

intentionally 

blank
Arts Strategies for Addressing the Opioid Crisis: Examining the Evidence 51

Evidence Gaps and Limitations: Moving Forward

This chapter identifies limitations to the studies included in this report, limitations to the report itself, and 

evidence gaps. To address these gaps, a number of directions for future research are recommended. 

Study Limitations

The most common limitation of the studies included in this report was small sample size, especially for studies 

on SUD. Small sample sizes could stem from insufficient or lack of funding; only 43 percent of pain management 

studies and 31 percent of SUD treatment studies identified a funding source. Many studies relied on small 

convenience samples, introducing several potential confounding factors (e.g., selection bias). Small sample sizes 

also limit statistical power and preclude the examination of subgroup differences to gauge if interventions 

worked differently for different groups of people (e.g., men versus women, participants with alcohol use 

disorder versus OUD). 

Most research was conducted within clinical settings—either postoperative hospital units or inpatient 

treatment units—limiting the generalizability of the findings to other settings. The studies’ focus on clinical 

settings also limited the intervention dosage, typically to single sessions for interventions offered in 

postoperative hospital and inpatient detoxification units. Likewise, few studies assessed the maintenance of 

outcomes over time.

In some cases, investigators served as both clinician and researcher by facilitating therapy sessions and 

administering outcome assessments. This dual role introduces response bias.

Finally, missing information from articles made it difficult to collect study characteristics. For example, it was 

difficult to distinguish between a music therapy intervention, which requires a credentialed professionalag

who has completed an approved and accredited music therapy program, and a nonsystematic music medicine 

or music-listening program. Most studies did not report credentialing details, and many were conducted in 

different countries with varying credentialing standards. As the field of arts and health advances, the need is 

growing for arts professionals to develop and follow professional standards of practice that ensure patient 

safety and avoidance of harm.98

Likewise, many music studies did not report details such as the type of music used, whether music was selected 

by participants or researchers, the names of musical pieces, or the music structure and characteristics. There 

has been a call in the literature to include clear and detailed explanations of the interventions used and why 

that intervention was selected.99

Finally, most studies did not report an effect size, making it difficult to understand the magnitude of the 

differences found. 

agIn contrast to other arts professionals, such as artists, performers, or artists in residence, certified creative arts therapists are fully traine

as artists and therapists. They have typically completed graduate study and should be board-certified, registered, and/or licensed by their 

corresponding creative arts therapy certification board. They must comply with discipline-specific clinical practice standards and codes of ethics 

and must meet continuing education requirements to maintain professional credentials. For more information, see Patricia Dewey Lambert and 

Jill Sonke, “Professionalizing Arts Management in Healthcare Facilities,” The Journal of Arts Management, Law, and Society 49, no. 3 (2019): 155–70, 

doi:10.1080/10632921.2018.1559264.
52 National Endowment for the Arts | arts.gov

Report Limitations

All literature reviews are subject to publication bias (i.e., the failure to publish study results because of the 

direction or strength of the findings).100 When journals publish only statistically or clinically significant results, 

they impact the conclusions of a literature review and consequently the information presented to researchers, 

health care providers, and policymakers.101

For this report, publication database searches were limited to peer-reviewed sources. Because music is the most 

prevalent art form in the peer-reviewed literature,102 this approach may have limited the number of studies 

on arts-based interventions other than music, such as visual arts or writing. A systematic search of white or 

gray literature, such as unpublished dissertations or theses, was not conducted, but white and gray literature 

identified through backward and forward reference searches (i.e., by following chains of citations and sources 

identified in the initial search) was reviewed.

In addition, while the search used a combination of Medical Subject Headings (MeSH) searching, keyword 

searching, and text word searching, searches were refined by limiting text word searching to titles only. This was 

done to ensure a more focused and relevant search. This means, however, that if an article included one of the 

search terms in the text but did not include that term as a MeSH heading, as a keyword, or in the article title, it 

would not have been picked up by the search. 

An integrative literature review, not a meta-analysis, was conducted. While this report describes the direction 

of the reported effects (i.e., positive or negative), it does not assess effectiveness of a specific intervention or 

examine differences between different types of interventions. 

Finally, program scan information in the report relies largely on informal conversations with program 

representatives and is exploratory in nature. Only programs with publicly available resources were identified for 

inclusion. 

Directions for Future Research

Findings and limitations of the literature review and program scan were used to identify directions for future 

research. This section offers suggestions by research question. 

Research Question 1. What is the evidence on the role of the arts in pain 

management?

More studies should assess the maintenance of benefits from arts-based pain management treatment 

over time. More than half the studies in the literature review took place in a hospital setting and assessed 

participants during the immediate postoperative period. Few studies followed up with participants after they 

left the hospital. One study of participants with chronic pain (including lumbar pain, fibromyalgia, inflammator

disease, or neurological disease) found that those who participated in music intervention sessions while 

hospitalized (n = 44) experienced an improvement in their pain level double than that seen in the control group 

(n = 43); this significant effect on pain was sustained for up to one month posthospitalization.103 Future studies 

should examine if postoperative, arts-based interventions can prevent the development of chronic pain and 

disability and/or chronic opioid use and OUD. Long-term follow-up studies should also examine dosage effects 

and the cost effectiveness and/or cost benefit of music interventions. Additional funding is needed to support 

these efforts. 
Arts Strategies for Addressing the Opioid Crisis: Examining the Evidence 53

Additional research is needed on the impact of arts-based interventions in non-hospital settings. While more 

than half the studies in the literature review took place in a hospital setting, the program scan identified artsbased programs implemented in community-based locations and the home. Semper Sound has the potential to 

offer home visits with board-certified music therapists, for example, and RVTRI CAT offers creative arts therapies 

using clinical video telehealth (i.e., real-time, two-way video chat). Such programs can engage participants for 

whom distance or disability limits accessibility to available rehabilitation services and resources and allow for 

long-term programming and follow-up, but more research is needed to strengthen their evidence base. Future 

research should also examine the impact of arts-based interventions that link clinical and community settings.

Future studies should examine the impact of arts-based interventions other than music. Only a handful of 

studies examined the impact of arts-based interventions other than music, and most had small sample sizes. 

One study of individuals with chronic low back pain (n = 30) found that participation in aerobic dance resulted 

in statistically significant positive effects on pain intensity, functional disability, and quality of life.104 Another 

study found that a literature-based intervention had a positive effect on the pain and psychological well-being of 

participants (n = 6) suffering from chronic pain, but it did not test statistical significance.105 Additional research is 

needed to inform the evidence base.

There is a need for additional research on the impact of arts-based interventions on chronic pain. Chronic pain 

is the most prevalent public health condition in the United States, affecting an estimated 20 percent of adults,106

yet only 31 percent of the reviewed studies targeted individuals with chronic pain. Those studies that did examine 

chronic pain found mostly positive effects. Participants (n = 37) with fibromyalgia who were asked to listen to 25 

minutes of researcher-selected music twice a day for 14 days reported a statistically significant decrease in pain 

between days one and 14 compared with control participants who did not listen to music.107 These and other, 

similar results suggest that music interventions can be an effective treatment option for individuals with chronic 

pain.

Future studies should consider using qualitative information to contextualize quantitative findings.

Quantitative data from a mixed methods study found that music listening and music therapy interventions were 

equally effective in reducing pain in individuals with cancer (n = 31). Some participants in the same study revealed 

that listening to music evoked intense memories of loss and trauma.108 These qualitative findings provide a more 

nuanced understanding of treatment effects, indicating a potential need for psychotherapeutic support for 

patients coping with intense emotions. 

Additional research is needed on the impact of arts-based interventions on the social aspects of pain 

management. The program scan found that, in addition to targeting physical pain, arts activities and therapies 

also target the psychological and social aspects of pain by emphasizing community-building around the arts and 

pain management for individuals, families, medical caregivers, and researchers. Anecdotes offered by Art Rx 

and others suggest the arts’ promise in addressing social stigma related to pain and helping individuals feel less 

isolated by their pain.

Future studies should examine arts-based interventions compared with and combined with standard care (e.g., 

pain medication) and other nonpharmacological treatments (e.g., acupuncture, massage therapy). One study 

examining the impact of massage alone (n = 13), massage with music (n = 13), music alone (n = 13), and standard 

care (n = 13) on participants’ anxiety and consumption of pain medicine found no significant differences between 

groups.109 Additional research is needed to inform the evidence base and to help inform which pain management 

strategies yield the best outcomes. 

There is a need for research to examine the mechanism of action in arts-based interventions. Music has been 

shown to influence activity in the medial prefrontal cortex and limbic/paralimbic brain structures involved in 

affective and cognitive modulation of pain.110, 111 However, less research exists to explain the mechanism of 

other arts-based interventions. Understanding mechanisms of action can lead to the design of more effective 

interventions. 
54 National Endowment for the Arts | arts.gov

Research Question 2. What is the evidence on the role of the arts in the prevention 

of SUD, including OUD?

Research is needed to examine the role of the arts in the prevention of SUD, particularly for young people. 

Several programs included in the scan draw on positive youth development theory and practice to help 

participants develop positive life skills and protective factors to prevent SUD, among other negative outcomes. 

Future research should examine how arts-based prevention programs can impact risk and protective factors 

related to SUD, including delinquency, psychiatric conditions, violence, and school dropout.112

Long-term studies are needed to examine how arts-based prevention programs can impact SUD directly.

Several program representatives spoke to the challenges of tracking long-term SUD prevention outcomes, 

including not having mechanisms to track youth after they complete the program. Young people who complete 

parole in the juvenile justice system are difficult to track, for example, once their records are erased. Programs 

should collaborate with researchers well-versed in program evaluation to measure program impacts and to 

identify strategies for long-term evaluation (e.g., engaging program alumni, linking to juvenile justice and 

academic data systems to track youth for as long as information is available). Demonstrating program impact 

through high-quality research could lead to additional or sustained funding. 

There is a need for studies that examine the link between the arts and the prevention of SUD within and 

across developmental periods. More research is needed to understand, for example, which arts-based 

strategies work for adolescents versus adults. Future studies should explore the impact of arts-based 

interventions on SUD prevention in a range of developmental stages, such as young children, adolescents, and 

adults. 

Future research should examine the link between the arts and the prevention of SUD by using a populationbased approach. A population health approach focuses on the health and overall wellness of broader 

populations (e.g., communities, neighborhoods, cities, states, nations) rather than providing acute care to 

individual patients.113 Some population-based research suggests a positive relationship between self-reported 

arts engagement and health. For example, a nationwide study in Norway found that participating frequently in 

music, singing, and theater appears to increase self-reported health for women and reduce mortality for men, 

regardless of cause.114 A study in Australia found that those who engaged in the arts for two or more hours per 

week reported significantly better mental well-being than those with lower levels of engagement.115 Future 

research should build on these studies to examine the link between the arts and the prevention of SUD in 

general populations. 

Future research should examine the impact of cultural relevancy and cultural attunement in arts-based 

prevention programs. The term cultural attunement describes additions to evidence-based therapies that 

are intended to boost engagement and retention of subcultural group members.ah Research has found that 

participants’ feelings about a program’s relevance can impact outcomes.116 Prevention programs not perceived 

as culturally relevant may have difficulty recruiting and retaining participants. Future research should examine 

if the cultural attunement or relevance of arts-based programs influences participant engagement, retention, 

and outcomes. It is important to note that the studies in this review were conducted across a wide variety of 

cultures, and results from one culture may not be generalizable to another.

ah Such additions might include providing services in clients’ native language, utilizing bicultural staff, and incorporating familiar cultural 

traditions. Attunement involves making changes to increase reach and engagement, but it does not include modifying core treatment 

components. Other terms, such as “culturally sensitive,” “culturally enhanced,” “culturally appropriate,” “culturally informed,” “culturally grounded,” 

“culture specific,” and “culturally focused,” have been used to describe deliberate efforts to increase the appeal and effectiveness of interventions 

that are used with subcultural groups. For more information, see Manuel Barrera Jr. et al., “Cultural Adaptations of Behavioral Health 

Interventions: A Progress Report,” Journal of Consulting and Clinical Psychology 81, no. 2 (2013): 196.
Arts Strategies for Addressing the Opioid Crisis: Examining the Evidence 55

Research Question 3. What is the evidence on the role of the arts in the treatment 

of SUD, including OUD?

Future research should assess outcomes related to substance use. Few studies in this review assessed 

outcomes related to substance use, such as relapse or abstinence, even though such outcomes are critical for 

treatment success. Future research should examine the relationship between arts-based interventions and 

substance use or abstinence. 

There is a need for studies that assess long-term measures of sustained recovery. Because most studies 

focused on individuals in inpatient settings, few examined long-term treatment outcomes. Individuals in 

detoxification settings, for example, typically remain in the unit for three to five days. To better inform effective 

treatment strategies, research is needed to examine the relationship between arts-based interventions and 

measures of sustained recovery, such as long-term abstinence. Long-term follow-up studies should also 

examine dosage effects and the cost-effectiveness of music interventions. 

There is a need for research on individuals with OUD. No studies in this review limited their sample to 

individuals with OUD. While OUD is similar to other SUDs in many respects, it has several unique features, 

including high relapse rates. Research suggests that the risk for relapse may be higher for OUD than it is 

for other types of SUD (e.g., one study reported a relapse rate of up to 91 percent for opiate-dependent 

individuals following detox117 compared with relapse rates of 40–60 percent for other types of SUD).118

Individuals with OUD may also have unique sociodemographic factors. Compared with individuals who have 

alcohol use disorder, individuals who have OUD are more likely to be single, be unemployed, belong to a lower 

socioeconomic status, or have a criminal record.119 Future research should examine the role of arts-based 

interventions in the treatment of OUD. 

Future studies should examine the impact of arts-based interventions other than music on SUD. The program 

scan found that arts-based programs use a variety of art forms to address SUD. Porch Light, for example, 

uses several art activities—including mural-making—to improve community awareness, reduce social stigma, 

and promote resilience and recovery (see Exhibit 19). However, only a handful of studies included in the 

literature review examined arts-based interventions other than music, and most of those had small sample 

sizes and did not test statistical significance. A preliminary study of a six-week theater project to facilitate 

community engagement and SUD recovery in veterans found that participants (n = 7) who remained active in 

the intervention reported improvements in social and occupational participation for up to six weeks afterward. 

Most participants were also abstinent during the intervention.120 A study of cinema for adults (n = 17) in a 

long-term residential treatment facility for SUD found that watching movies helped participants talk about 

their feelings and think about the future in a hopeful and positive way.121 These results suggest that arts-based 

interventions may help people recovering from SUDs, but larger efficacy and effectiveness studies are needed 

to examine whether results can be linked to participation in the intervention.

Arts-based programs need to partner with researchers in the field of SUD. While the program scan highlights 

personal testimonials from participants of programs that use arts-based interventions other than music to 

prevent or treat SUD, a gap exists between what is happening in practice and the empirical evidence base. 

There is a need for a wider array of arts-based prevention programs to collaborate with researchers who have 

expertise in program evaluation to measure the impact of these programs.

The field of arts in health needs to establish core outcomes and reporting guidelines. This report found 

great variation in the quality and consistency of reporting. Missing information made it difficult to collect and 

synthesize study characteristics. Creating a shared set of core outcomes and reporting guidelines for artsbased interventions would improve research strategies, reporting, evidence synthesis, and future collaboration.
56 National Endowment for the Arts | arts.gov

Exhibit 19. Porch Light

Philadelphia residents coping with mental health disorders and SUD find a safe haven in the Porch Light 

program. Run by Mural Arts Philadelphia, Porch Light brings together teams of participants, artists, and 

behavioral health providers to create murals that reflect issues of importance to the community, including 

trauma, homelessness, and recovery. Participants gather at year-round workshops, classes, community 

events, and paint days. 

Porch Light operates three community storefronts in Southeast Philadelphia, Northeast Philadelphia, 

and Kensington. Since 2017, offerings at the Kensington storefront have included mural making as well as 

Tuesday Tea and Textiles, Journaling for Survivors, Patches and Prayer Flags, and open mic nights. Certified 

recovery specialists work alongside participants as peer supports and help connect them to services. All 

staff are trained to administer Narcan on site. 

“[We] follow the motto of art as harm reduction,” says Porch Light director Nadia Malik. “Our hope is to try 

to reduce some of the stigma around [OUD]. ... We don’t have any judgment for folks.” 

So far, the Kensington storefront has had more than 5,000 interactions with community members. Many 

engage with multiple classes and events throughout the week. Seeing individuals return to the program is a 

sign of success, Malik says—a reflection of community engagement and growing trust.
Arts Strategies for Addressing the Opioid Crisis: Examining the Evidence 57

Conclusion

The available evidence suggests that music interventions may reduce participants’ pain, reduce the amount of pain 

medication they take, improve their SUD treatment readiness and motivation, and reduce craving. Few studies 

examined art forms other than music, limiting the ability to draw conclusions for those art forms. Because most 

studies evaluated the impact of music-based interventions on individuals in hospital settings, results are not 

generalizable to other treatment settings.

Given the critical need to identify effective strategies for managing pain and preventing and treating SUD, future 

research on arts-based interventions should examine the following:

• Maintenance of pain management and SUD treatment benefits over time

• Outcomes related to SUD prevention

• Outcomes related to arts-based interventions other than music

• Delivery in community settings, such as social service organizations

Implications for the Opioid Crisis

Few of the studies and programs included in this report examined the relationship between the arts and opioid 

use in the context of pain management or SUD treatment—possibly because of timing. In October 2018, the 

SUPPORT for Patients and Communities Act became law. Among its many goals, the legislation aims to promote 

research to address the opioid crisis, particularly studies of alternative treatments for pain.122 This research will 

likely not be available for review for several years. Nonetheless, several implications for the present-day opioid 

crisis were identified. 

The literature review found that music-based interventions may reduce postoperative pain and reduce the 

consumption of pain medication. This finding is particularly important because individuals often receive opioid 

therapy to treat an acute problem, such as a surgery or injury, and then transition to chronic use.123 Musicbased interventions may also reduce chronic pain, which is important given the prevalence of chronic pain in 

the United States. Together, these findings suggest that music has a role within integrated and comprehensive 

approaches to pain management. However, additional research is needed to establish clinical guidance and 

indications for use.124

The literature review also found that music-based interventions can increase treatment motivation and 

readiness to change for participants at inpatient SUD treatment centers. These findings suggest music’s 

potential as a complementary part of a comprehensive treatment solution. Offered in combination with 

evidence-based clinical components, such as behavioral therapies, medications, and recovery support 

services,125 music may improve treatment outcomes for individuals with OUD.

These findings are promising because music is enjoyable for most individuals and music-based pain 

management strategies are easy to learn and inexpensive to implement at home. But additional research is 

needed to examine the specific impact of music interventions on OUD. Future research should also examine the 

cost-effectiveness of music interventions for SUD.

Arts-based programs included in the program scan have not measured outcomes related to OUD; still, program 

representatives believe their efforts can help to achieve the following:
58 National Endowment for the Arts | arts.gov

• Prevent or reduce the need for prescribed opioids. For example, Art Rx emphasizes partnerships with 

healthcare practitioners who manage opioid regimes for individuals with chronic pain, with the aim that the 

program can supplement tapering efforts.

• Build protective factors to prevent opioid use. Programs such as Moving in the Spirit, M3, and Prodigy 

Cultural Arts Program engage young people in the arts to help them develop positive life skills to prevent 

recreational opioid use. 

• Address stigma and promote recovery. The Porch Light program’s Kensington storefront explicitly engages 

individuals with and/or in recovery from OUD to address the stigma of use within the community and to 

promote recovery. 

Overall, these findings suggest that music interventions are a promising strategy to enhance pain management and 

SUD prevention and treatment efforts by optimizing physical, psychological, and social well-being.
Arts Strategies for Addressing the Opioid Crisis: Examining the Evidence 59

Glossary

Acute pain: Pain that typically lasts less than three months and usually has a clear connection to a physically 

identifiable pain-generating pathology or tissue damage. Expected to resolve as the tissue damage heals.126

Analgesic: A drug acting to relieve pain.

Arts: Various branches of creative activity, such as music, painting, literature, and dance. Can include informal 

activities (e.g., listening to music), formal activities (e.g., music class), and creative arts therapies (e.g., a structured 

therapeutic program using music led by a certified music therapist). 

Chronic pain: Pain that is present for longer than three months and may or may not have a clear and current 

connection to an identifiable tissue-based cause, structural injury, or defect.127

Creative arts therapies: Therapies that intentionally apply the arts to ameliorate disability and illness and to 

improve health and wellness.128 As a part of their training, most arts therapists complete professional practice 

requirements and obtain certification. The National Coalition of Creative Arts Therapies Associations includes the 

following:

• Art therapy

• Dance/movement therapy 

• Drama therapy

• Music therapy

• Poetry therapy 

• Psychodrama

Mixed Methods Appraisal Tool (MMAT): A tool used to appraise and describe studies included in systematic 

mixed studies reviews. The MMAT includes five individual checklists, one each for qualitative studies, quantitative 

randomized control trials, quantitative nonrandomized studies, quantitative descriptive studies, and mixed methods 

studies.129

Mixed methods study: Research study that combines qualitative and quantitative methods. Common research 

designs include convergent design, sequential explanatory design, and sequential exploratory design.130

Nonpharmacological treatments: Interventions that do not involve medications, including exercise, mind-body 

practices, psychological therapies, multidisciplinary rehabilitation, mindfulness practices, manual therapies, physical 

modalities, and acupuncture.131

Opioid: Natural or synthetic chemicals that interact with opioid receptors on nerve cells in the body and brain and 

reduce the intensity of pain signals and feelings of pain. This class of drugs includes the illegal drug heroin; synthetic 

opioids, such as fentanyl; and pain medications available legally by prescription, such as oxycodone, hydrocodone, 

codeine, morphine, and many others.132

Opioid use disorder: A problematic pattern of opioid use leading to clinically significant impairment or distress, 

as manifested by at least two of 11 designated criteria (e.g., taking more opioids than intended, craving opioids, 

experiencing withdrawal symptoms when opioids are not taken) within a 12-month period.133

Protective factors: Characteristics associated with a lower likelihood of negative outcomes or that reduce a risk 

factor’s impact.134
60 National Endowment for the Arts | arts.gov

Qualitative study: Research study that seeks to explore and understand the meaning individuals or groups ascribe 

to a social or human problem. Common qualitative research approaches include ethnography, phenomenology, 

narrative research, grounded theory, case study, and qualitative description.135

Quantitative descriptive study: Research study used to monitor a population, planning, and generating hypotheses 

and that is generally concerned with the existing distribution of variables without much regard to causal 

relationships. Common research designs include incidence or prevalence study with comparison group, survey, case 

series, and case report.136

Quantitative non-randomized study: Research study that estimates the effectiveness of an intervention or studying 

other exposures that do not use randomization to allocate units to comparison groups. Common research designs 

include non-randomized controlled trials, cohort study, case-control study, and cross-sectional analytic study.137

Randomized controlled clinical trial (RCT): A clinical study in which individual participants are allocated to 

intervention or control groups by randomization (intervention assigned by researchers).138

Risk factors: Characteristics at the biological, psychological, family, community, or cultural level that precede and are 

associated with a higher likelihood of negative outcomes.139

Substance use disorder (SUD):aiA disorder that occurs when the recurrent use of alcohol and/or drugs causes 

clinically and functionally significant impairment, such as health problems, disability, and failure to meet major 

responsibilities at work, school, or home.140 The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition

(DSM-5) classifies substance use disorder as mild, moderate, or severe, depending on how many diagnostic criteria 

(e.g., hazardous use, withdrawal, tolerance) are met within a 12-month period.141

ai The term “SUD” is used throughout this report in accordance with the DSM-5 definition published in 2013. When describing specific 

studies, many of which were published before 2013, the author’s original language is used. In 2015, the International Society of Addiction 

Journal Editors recommended against using stigmatizing terminology, most notably “abuse” and “abuser,” in published addiction science. For 

more information, see The International Society of Addiction Journal Editors, Statements and Guidelines, http://www.isaje.net/addictionterminology.html.
Arts Strategies for Addressing the Opioid Crisis: Examining the Evidence 61

Appendix A. List of Studies Included in the 

Literature Review

Exhibits A1-A3 list the articles included in the literature review. 

Exhibit A1. Pain Management Studies

Ajorpaz, Neda Mirbagher, Abouzar Mohammadi, Hamed Najaran, and Shala Khazaei. “Effect of Music on 

Postoperative Pain in Patients under Open Heart Surgery.” Nursing and Midwifery Studies 3, no. 3 (2014). https://doi.

org/10.17795/nmsjournal20213.

Allred, Kelly D., Jacqueline F. Byers, and Mary Lou Sole. “The Effect of Music on Postoperative Pain and Anxiety.” 

Pain Management Nursing: Official Journal of the American Society of Pain Management Nurses 11, no. 1 (2010): 15–25. 

https://doi.org/10.1016/j.pmn.2008.12.002.

Alparslan, Güler Balcı, Burcu Babadag, Ayse Özkaraman, Pınar Yıldız, Ahmet Musmul, and Cengiz Korkmaz. “Effects 

of Music on Pain in Patients with Fibromyalgia.” Clinical Rheumatology 35, no. 5 (2016): 1317–21.

Ames, Nancy, Rebecca Shuford, Li Yang, Brad Moriyama, Meredith Frey, Florencia Wilson, Thiruppavai 

Sundaramurthi. “Music Listening among Postoperative Patients in the Intensive Care Unit: A Randomized 

Controlled Trial with Mixed-Methods Analysis.” Integrative Medicine Insights 12 (2017):1-13. https://doi.

org/10.1177/1178633717716455.

Arruda, Maurilene Andrade Lima Bacelar, Marília Arrais Garcia, and João Batista Santos Garcia. “Evaluation of the 

Effects of Music and Poetry in Oncologic Pain Relief: A Randomized Clinical Trial.” Journal of Palliative Medicine 19, 

no. 9 (2016): 943–48.

Billington, Josie, Anne Louise Humphreys, Andrew Jones, and Kate McDonnell. “A Literature-Based Intervention for 

People with Chronic Pain.” Arts & Health 8, no. 1 (2016): 13–31.

Bradt, Joke, Noah Potvin, Amy Kesslick, Minjung Shim, Donna Radl, Emily Schriver, Edward J. Gracely, and Lydia T. 

Komarnicky-Kocher. “The Impact of Music Therapy versus Music Medicine on Psychological Outcomes and Pain in 

Cancer Patients: A Mixed Methods Study.” Supportive Care in Cancer 23, no. 5 (2015): 1261–71.

Burrai, Francesco, Valentina Micheluzzi, and Valentina Bugan. “Effects of Live Sax Music on Various Physiological 

Parameters, Pain Level, and Mood Level in Cancer Patients: A Randomized Controlled Trial.” Holistic Nursing Practice

28, no. 5 (2014): 301–11.

Castrillon, Tabitha, William J. Hanney, Carey E. Rothschild, Morey J. Kolber, Xinliang Liu, and Michael Masaracchio. 

“The Effects of a Standardized Belly Dance Program on Perceived Pain, Disability, and Function in Women with 

Chronic Low Back Pain.” Journal of Back and Musculoskeletal Rehabilitation 30, no. 3 (2017): 477–96.

Clements-Cortés, Amy. “Artful Wellness: Attending Chamber Music Concert Reduces Pain and Increases Mood and 

Energy for Older Adults.” The Arts in Psychotherapy 52 (2017): 41–49. https://doi.org/10.1016/j.aip.2016.10.001. 

Comeaux, Tressa, and Susan Steele-Moses. “The Effect of Complementary Music Therapy on the Patient’s 

Postoperative State Anxiety, Pain Control, and Environmental Noise Satisfaction.” Pain Control 22, no. 5 (2013): 7. 
62 National Endowment for the Arts | arts.gov

Costa, Fiona, Adam Ockelford, and David J. Hargreaves. “The Effect of Regular Listening to Preferred Music on Pain, 

Depression and Anxiety in Older Care Home Residents.” Psychology of Music 46, no. 2 (2018): 174–91. https://doi.

org/10.1177/0305735617703811. 

Czamanski-Cohen, Johanna, O. Sarid, E. Huss, A. Ifergane, L. Niego, and J. Cwikel. “CB-ART—The Use of a Hybrid 

Cognitive Behavioral and Art Based Protocol for Treating Pain and Symptoms Accompanying Coping with Chronic 

Illness.” The Arts in Psychotherapy 41, no. 4 (2014): 320–28.

Ebneshahidi, Amin, and Masood Mohseni. “The Effect of Patient-Selected Music on Early Postoperative Pain, 

Anxiety, and Hemodynamic Profile in Cesarean Section Surgery.” The Journal of Alternative and Complementary 

Medicine 14, no. 7 (2008): 827–31.

Finlay, Katherine A. “Music-Induced Analgesia in Chronic Pain: Efficacy and Assessment through a Primary-Task 

Paradigm.” Psychology of Music 42, no. 3 (2014): 325–46. https://doi.org/10.1177/0305735612471236. 

Fredenburg, Hilary A., and Michael J. Silverman. “Effects of Music Therapy on Positive and Negative Affect and Pain 

with Hospitalized Patients Recovering from a Blood and Marrow Transplant: A Randomized Effectiveness Study.” The 

Arts in Psychotherapy 41, no. 2 (2014): 174–80.

Garza-Villarreal, Edurado A., Andrew D. Wilson, Lene Vase, Elvira Brattico, Fernando A. Barrios, Troels Staehelin 

TSJ Jensen, Juan Ignacio Romero-Romo, and Peter Vuust. “Music Reduces Pain and Increases Functional Mobility in 

Fibromyalgia.” Frontiers in Psychology 5 (2014): 90.

Ghezeljeh, T. Najafi, F. Mohades Ardebili, and F. Rafii. “The Effects of Massage and Music on Pain, Anxiety and 

Relaxation in Burn Patients: Randomized Controlled Clinical Trial.” Burns 43, no. 5 (2017): 1034–43.

Good, Marion, and Sukhee Ahn. “Korean and American Music Reduces Pain in Korean Women after Gynecologic 

Surgery.” Pain Management Nursing 9, no. 3 (2008): 96–103. https://doi.org/10.1016/j.pmn.2008.02.002. 

Good, Marion, Gene Cranston Anderson, Michael Stanton-Hicks, Jeffrey A. Grass, and Michael Makii. “Relaxation 

and Music Reduce Pain after Gynecologic Surgery.” Pain Management Nursing 3, no. 2 (2002): 61–70.

Good, Marion, Gene Cranston Anderson, Sukhee Ahn, Xiaomei Cong, and Michael Stanton-Hicks. “Relaxation and 

Music Reduce Pain following Intestinal Surgery.” Research in Nursing & Health 28, no. 3 (2005): 240–51.

Good, Marion, Michael Stanton-Hicks, Jeffrey A. Grass, Gene Cranston Anderson, Hui-Ling Lai, Varunyupa 

Roykulcharoen, and Patricia A. Adler. “Relaxation and Music to Reduce Postsurgical Pain.” Journal of Advanced 

Nursing 33, no. 2 (2001): 208–15.

Good, Marion, Michael Stanton-Hicks, Jeffrey A. Grass, Gene Cranston Anderson, Charles Choi, Laree J. 

Schoolmeesters, and Ali Salman. “Relief of Postoperative Pain with Jaw Relaxation, Music and Their Combination.” 

Pain 81, no. 1–2 (1999): 163–72.

Guétin, Stéphane, Patrick Ginies, Didier Kong A. Siou, Marie-Christine Picot, Christelle Pommie, Elisabeth Guldner, 

Anne-Marie Gosp, Katelyne Ostyn, Emmanuel Coudeyre, and Jacques Touchon.. “The Effects of Music Intervention 

in the Management of Chronic Pain: A Single-Blind, Randomized, Controlled Trial.” The Clinical Journal of Pain 28, no. 

4 (2012): 329–37.

Haack, Brenton, and Michael J. Silverman. “Effects of Guitar Accompaniment Style within Patient Preferred Live 

Music on Mood and Pain with Hospitalized Patients on a Solid Organ Transplant Unit: A Three Group Randomized 

Pilot Study.” The Arts in Psychotherapy 52 (2017): 32–40. 

Hsu, Kuo-Cheng, Li Fen Chen, and Pi Hsia Hsiep. “Effect of Music Intervention on Burn Patients’ Pain and Anxiety 

during Dressing Changes.” Burns 42, no. 8 (2016): 1789–96. 
Arts Strategies for Addressing the Opioid Crisis: Examining the Evidence 63

Huang, Shih-Tzu, Marion Good, and Jaclene A. Zauszniewski. “The Effectiveness of Music in Relieving Pain in Cancer 

Patients: A Randomized Controlled Trial.” International Journal of Nursing Studies 47, no. 11 (2010): 1354–62. 

Ikonomidou, Eleni, Anette Rehnström, and Ole Naesh. “Effect of Music on Vital Signs and Postoperative Pain.” AORN 

Journal 80, no. 2 (2004): 269–78.

Innes, Kim E., Terry Kit Selfe, Sahiti Kandati, Sijin Wen, and Zenzi Huysmans. “Effects of Mantra Meditation versus 

Music Listening on Knee Pain, Function, and Related Outcomes in Older Adults with Knee Osteoarthritis: An 

Exploratory Randomized Clinical Trial (RCT).” Edited by Mark Moss. Evidence-Based Complementary and Alternative 

Medicine (2018): 19.

Jafari, Hedayat, Amir Emami Zeydi, Soghra Khani, Ravanbakhsh Esmaeili, and Aria Soleimani. “The Effects of 

Listening to Preferred Music on Pain Intensity after Open Heart Surgery.” Iranian Journal of Nursing and Midwifery 

Research 17, no. 1 (2012): 1.

Johnson, Alisa J., Zoltan Kekecs, R. Lynae Roberts, Russell Gavin, Kathleen Brown, and Gary R. Elkins. “Feasibility of 

Music and Hypnotic Suggestion to Manage Chronic Pain.” International Journal of Clinical and Experimental Hypnosis 

65, no. 4 (2017): 452–65.

Kahloul, Mohamed, Salah Mhamdi, Mohamed Said Nakhli, Ahmed Nadhir Sfeyhi, Mohamed Azzaza, Ajmi Chaouch, 

and Walid Naija. “Effects of Music Therapy under General Anesthesia in Patients Undergoing Abdominal Surgery.” 

Libyan Journal of Medicine 12, no. 1 (2017): 1260886. https://doi.org/10.1080/19932820.2017.1260886.

Kenny, Dianna T., and Gavin Faunce. “The Impact of Group Singing on Mood, Coping, and Perceived Pain in Chronic 

Pain Patients Attending a Multidisciplinary Pain Clinic.” Journal of Music Therapy 41, no. 3 (2004): 241–58.

Ko, Shuk Yee, Doris Y. P. Leung, and Eliza M. L. Wong. “Effects of Easy Listening Music Intervention on Satisfaction, 

Anxiety, and Pain in Patients Undergoing Colonoscopy: A Pilot Randomized Controlled Trial.” Clinical Interventions in 

Aging 14 (2019): 977–86.

Koebner, Ian J., Scott M. Fishman, Debora Paterniti, Doris Sommer, Claudia M. Witt, Deborah Ward, and Jill G. 

Joseph. “The Art of Analgesia: A Pilot Study of Art Museum Tours to Decrease Pain and Social Disconnection among 

Individuals with Chronic Pain.” Pain Medicine 20, no. 4 (2018): 681–91.

Korhan, Esra Akin, Meltem Uyar, Can Eyigör, Gülendam Hakverdioglu Yönt, Serkan Çelik, and Leyla Khorshıd. “The  ̆

Effects of Music Therapy on Pain in Patients with Neuropathic Pain.” Pain Management Nursing 15, no. 1 (2014): 306–14.

Krishnaswamy, Priyadharshini, and Shoba Nair. “Effect of Music Therapy on Pain and Anxiety Levels of Cancer 

Patients: A Pilot Study.” Indian Journal of Palliative Care 22, no. 3 (2016): 307. 

Kulkarni, S., P. C. D. Johnson, S. Kettles, and R. S. Kasthuri. “Music during Interventional Radiological Procedures, 

Effect on Sedation, Pain and Anxiety: A Randomised Controlled Trial.” The British Journal of Radiology 85, no. 1016 

(2012): 1059–63. 

Kumar, Thirumurthy Sathish, M. Muthuraman, and R. Krishnakumar. “Effect of the Raga Ananda Bhairavi in Post 

Operative Pain Relief Management.” Indian Journal of Surgery 76, no. 5 (2014): 363–70. 

Kurdi, Madhuri S., and Vinod Gasti. “Intraoperative Meditation Music as an Adjunct to Subarachnoid Block for 

the Improvement of Postoperative Outcomes Following Cesarean Section: A Randomized Placebo-Controlled 

Comparative Study.” Anesthesia: Essays and Research 12, no. 3 (2018): 618. 

Kwan, Melanie, and Angeline Soek Tian Seah. “Music Therapy as a Non-Pharmacological Adjunct to Pain 

Management: Experiences at an Acute Hospital in Singapore.” Progress in Palliative Care 21, no. 3 (July 2013): 151–57. 

https://doi.org/10.1179/1743291X12Y.0000000042. 
64 National Endowment for the Arts | arts.gov

Kwekkeboom, Kristine L. “Music versus Distraction for Procedural Pain and Anxiety in Patients with Cancer.” 

Oncology Nursing Forum 30, no. 3 (2003): 433–40. https://doi.org/10.1188/03.ONF.433-440. 

Li, Xiao-Mei, Hong Yan, Kai-Na Zhou, Shao-Nong Dang, Duo-Lao Wang, and Yin-Ping Zhang. “Effects of Music 

Therapy on Pain among Female Breast Cancer Patients after Radical Mastectomy: Results from a Randomized 

Controlled Trial.” Breast Cancer Research and Treatment 128, no. 2 (2011): 411–19. 

Lin, Pi-Chu, Man-Ling Lin, Li-Ching Huang, Hsiu-Chu Hsu, and Chiong-Chu Lin. “Music Therapy for Patients Receiving 

Spine Surgery.” Journal of Clinical Nursing 20, no. 7–8 (2011): 960–68.

Macdonald, Raymond A., Laura A. Mitchell, Teresa Dillon, Michael G. Serpell, John B. Davies, and Euan A. Ashley. 

“An Empirical Investigation of the Anxiolytic and Pain Reducing Effects of Music.” Psychology of Music 31, no. 2 

(2003): 187–203.

Madson, Amy T., and Michael J. Silverman. “The Effect of Music Therapy on Relaxation, Anxiety, Pain Perception, 

and Nausea in Adult Solid Organ Transplant Patients.” Journal of Music Therapy 47, no. 3 (2010): 220–32. https://doi.

org/10.1093/jmt/47.3.220. 

Masuda, Takahiro, Kei Miyamoto, and Katsuji Shimizu. “Effects of Music Listening on Elderly Orthopaedic 

Patients during Postoperative Bed Rest.” Nordic Journal of Music Therapy 14, no. 1 (2005): 4–14. https://doi.

org/10.1080/08098130509478121. 

McCaffrey, Ruth, and Edward Freeman. “Effect of Music on Chronic Osteoarthritis Pain in Older People.” Journal of 

Advanced Nursing 44, no. 5 (December 2003): 517–24. 

McCaffrey, Ruth, and Rozzano Locsin. “The Effect of Music on Pain and Acute Confusion in Older Adults Undergoing 

Hip and Knee Surgery.” Holistic Nursing Practice 20, no. 5 (2006): 218–24. 

McRee, Laura D., Stacie Noble, and Alice Pasvogel. “Using Massage and Music Therapy to Improve Postoperative 

Outcomes.” AORN Journal 78, no. 3 (2003): 433–47. https://doi.org/10.1016/S0001-2092(06)60754-0. 

Mercadíe, Lolita, Gérard Mick, Stéphane Guétin, and Emmanuel Bigand. “Effects of Listening to Music versus 

Environmental Sounds in Passive and Active Situations on Levels of Pain and Fatigue in Fibromyalgia.” Pain 

Management Nursing 16, no. 5 (2015): 664–71.

Miladinia, Mojtaba, Amir Hosein Pishgooie, Shahla Aliyari, and Elham Mousavi Nouri. “The Comparison of the Effect 

of Two Complementary Medicine Methods (Music Therapy and Massage Therapy) on Postoperative Acute Pain 

after Abdominal Surgery: A Randomized Clinical Trial Study.” Iran Red Crescent Med Journal 19, no. 6 (2017): e14974. 

doi:10.5812/ircmj.1497.

Miladinia, Mojtaba, Shahram Baraz, and Kourosh Zarea. “Controlling Acute Post-Operative Pain in Iranian Children 

with Using of Music Therapy.” International Journal of Pediatrics 4, no. 5 (2016): 1725–30. 

Motahedian, Ellahe, Saeid Movahedirad, Ebrahim Hajizadeh, and Marzieh Lak. “The Effect of Music Therapy on 

Postoperative Pain Intensity in Patients under Spinal Anesthesia.” Iranian Journal of Critical Care Nursing 5, no. 3 

(2012): 139–44. 

Nilsson, Ulrica, Mitra Unosson, and Narinder Rawal. “Stress Reduction and Analgesia in Patients Exposed to Calming 

Music Postoperatively: A Randomized Controlled Trial.” European Journal of Anaesthesiology 22, no. 2 (2005): 96–102. 

Nilsson, Ulrica, Narinder Rawal, Björn Enqvist, and Mitra Unosson. “Analgesia Following Music and Therapeutic 

Suggestions in the PACU in Ambulatory Surgery; a Randomized Controlled Trial.” Acta Anaesthesiologica Scandinavica 

47, no. 3 (2003): 278–83. 
Arts Strategies for Addressing the Opioid Crisis: Examining the Evidence 65

Nilsson, Ulrica, Narinder Rawal, and Mitra Unosson. “A Comparison of Intra-Operative or Postoperative Exposure to 

Music—a Controlled Trial of the Effects on Postoperative Pain.” Anaesthesia 58, no. 7 (2003): 699–703. https://doi.

org/10.1046/j.1365-2044.2003.03189_4.x. 

Okafor, U. A. C., T. A. Solanke, S. R. A. Akinbo, and D. O. Odebiyi. “Effect of Aerobic Dance on Pain, Functional 

Disability and Quality of Life on Patients with Chronic Low Back Pain.” South African Journal of Physiotherapy 68, no. 3 

(2012): 11–14. https://doi.org/10.4102/sajp.v68i3.18. 

Onieva-Zafra, María Dolores, Adelaida María Castro-Sánchez, Guillermo A. Matarán-Peñarrocha, and Carmen 

Moreno-Lorenzo. “Effect of Music as Nursing Intervention for People Diagnosed with Fibromyalgia.” Pain 

Management Nursing 14, no. 2 (2013): e39–e46. 

Özer, Nadiye, Zeynep Karaman Özlü, Sevban Arslan, and Nezihat Günes. “Effect of Music on Postoperative Pain and 

Physiologic Parameters of Patients after Open Heart Surgery.” Pain Management Nursing 14, no. 1 (2013): 20–28. 

https://doi.org/10.1016/j.pmn.2010.05.002. 

Pongan, Elodie, Barbara Tillmann, Yohana Leveque, Béatrice Trombert, Jean Claude Getenet, Nicolas Auguste, 

Virginie Dauphinot, Hanane El Haouari, Malou Navez, Jean-Michel Dorey, Pierre Krolak-Salmon. “Can Musical or 

Painting Interventions Improve Chronic Pain, Mood, Quality of Life, and Cognition in Patients with Mild Alzheimer’s 

Disease? Evidence from a Randomized Controlled Trial.” Journal of Alzheimer’s Disease 60, no. 2 (2017): 663–77. 

https://doi.org/10.3233/JAD-170410. 

Pothoulaki, M., R.A.R. MacDonald, P. Flowers, E. Stamataki, V. Filiopoulos, D. Stamatiadis, Ch. P. Stathakis. “An 

Investigation of the Effects of Music on Anxiety and Pain Perception in Patients Undergoing Haemodialysis 

Treatment.” Journal of Health Psychology 13, no. 7 (2008): 912–20.

Rodgers-Melnick, Samuel N., Nadine Matthie, Coretta Jenerette, Tara J. Griest Pell, Deforia Lane, Pingfu Fu, 

Seunghee Margevicius, and Jane A. Little. “The Effects of a Single Electronic Music Improvisation Session on the Pain 

of Adults with Sickle Cell Disease: A Mixed Methods Pilot Study.” Journal of Music Therapy 55, no. 2 (2018): 156–85.

Selle, Eric Walter, and Michael Joseph Silverman. “A Randomized Feasibility Study on the Effects of Music Therapy in 

the Form of Patient-Preferred Live Music on Mood and Pain in Patients on a Cardiovascular Unit.” Arts & Health 9, no. 

3 (2017): 213–23.

Sen, Hüseyin, Ali Sizlan, Ömer Yanarates ̧, Mustafa Kul, Emre Kılıç, Sezai Özkan, and Güner Dag ̆ li. “The Effect of Musical 

Therapy on Postoperative Pain after Caesarean Section.” TAF Preventive Medicine Bulletin 8, no. 2 (2009): 107–12.

Sen, Hüseyin, Ömer Yanarates ̧, Ali Sizlan, Emre Kiliç, Sezai Özkan, And Güner Dagli. “The Efficiency and Dur  ̆ ation of 

the Analgesic Effects of Musical Therapy on Postoperative Pain.” The Journal of the Turkish Society of Algology 22, no. 4 

(2010): 145–50.

Sendelbach, Sue E., Margo A. Halm, Karen A. Doran, Elaine Hogan Miller, and Philippe Gaillard. “Effects of Music 

Therapy on Physiological and Psychological Outcomes for Patients Undergoing Cardiac Surgery.” Journal of 

Cardiovascular Nursing 21, no. 3 (2006): 194–200. https://doi.org/10.1097/00005082-200605000-00007.

Sfakianakis, Michail Zografakis, Mariadni Karteraki, Kataki Panayiota, Olga Christaki, Evangelia Sorrou, Vasileia 

Chatzikou, and Evangelos Melidoniotis. “Effect of Music Therapy Intervention in Acute Postoperative Pain among 

Obese Patients.” International Journal of Caring Sciences 10, no. 2 (2017): 937–45.

Shella, Tamara A. “Art Therapy Improves Mood, and Reduces Pain and Anxiety When Offered at Bedside during 

Acute Hospital Treatment.” The Arts in Psychotherapy 57 (2018): 59–64.

Shertzer, Kay E., and Juanita Fogel Keck. “Music and the PACU Environment.” Journal of PeriAnesthesia Nursing 16, 

no. 2 (April 2001): 90–102. https://doi.org/10.1053/jpan.2001.22594. 
66 National Endowment for the Arts | arts.gov

Siedliecki, Sandra L., and Marion Good. “Effect of Music on Power, Pain, Depression and Disability.” Journal of 

Advanced Nursing 54, no. 5 (2006): 553–62. 

Taghinejad, Hamid, Ali Delpisheh, and Zeinab Suhrabi. “Comparison between Massage and Music Therapies 

to Relieve the Severity of Labor Pain.” Women’s Health 6, no. 3 (May 2010): 377–81. https://doi.org/10.2217/

WHE.10.15. 

Tan, Xueli, Charles J. Yowler, Dennis M. Super, and Richard B. Fratianne. “The Efficacy of Music Therapy Protocols 

for Decreasing Pain, Anxiety, and Muscle Tension Levels during Burn Dressing Changes: A Prospective Randomized 

Crossover Trial.” Journal of Burn Care & Research 31, no. 4 (2010): 590–97.

Tse, Mimi M. Y., M. F. Chan, and Iris F. F. Benzie. “The Effect of Music Therapy on Postoperative Pain, Heart Rate, 

Systolic Blood Pressure and Analgesic Use Following Nasal Surgery.” Journal of Pain & Palliative Care Pharmacotherapy 

19, no. 3 (January 2005): 21–29. 

Vaajoki, Anne, Anna-Maija Pietilä, Päivi Kankkunen, and Katri Vehviläinen-Julkunen. “Effects of Listening to Music 

on Pain Intensity and Pain Distress after Surgery: An Intervention.” Journal of Clinical Nursing 21, no. 5–6 (2012): 

708–17.

Voss, Jo A., Marion Good, Bernice Yates, Mara M. Baun, Austin Thompson, and Melody Hertzog. “Sedative Music 

Reduces Anxiety and Pain during Chair Rest after Open-Heart Surgery.” Pain 112, no. 1–2 (2004): 197–203. https://

doi.org/10.1016/j.pain.2004.08.020.

Wang, Yichun, Haoke Tang, Qulian Guo, Jingshi Liu, Xiaohong Liu, Junming Luo, and Wenqian Yang. “Effects of 

Intravenous Patient-Controlled Sufentanil Analgesia and Music Therapy on Pain and Hemodynamics after Surgery 

for Lung Cancer: A Randomized Parallel Study.” The Journal of Alternative and Complementary Medicine 21, no. 11 

(2015): 667–72.

Yaghoubinia, Fariba, Ali Navidian, Sara Sheikh, Enayatollah Safarzai, and Smna Tabatabaei. “Effect of Music Therapy 

and Reflexology on Pain in Unconscious Patients: A Randomized Clinical Trial.” International Journal of Medical 

Research & Health Sciences 5, no. 9 (2016): 288–95.

Zengin, Suat, Sinem Kabul, Behcet Al, Emine Sarcan, Mehmet Dogan, and Cuma Yildirim. “Effects of Music Ther  ̆ apy 

on Pain and Anxiety in Patients Undergoing Port Catheter Placement Procedure.” Complementary Therapies in 

Medicine 21, no. 6 (2013): 689–96.
Arts Strategies for Addressing the Opioid Crisis: Examining the Evidence 67

Exhibit A2. Substance Use Disorder Prevention Study

Stephens-Hernandez, Aileen B., Jonathan N. Livingston, Karen Dacons-Brock, Howard L. Craft, Amura Cameron, 

Steven O. Franklin, and Allyn C. Howlett. “Drama-Based Education to Motivate Participation in Substance Abuse 

Prevention.” Substance Abuse Treatment, Prevention, and Policy 2, no. 1 (2007): 11. 

Exhibit A3. Substance Use Disorder Treatment Studies

Abdollahnejad, Mohammad Reza. “Music Therapy in the Tehran Therapeutic Community.” Therapeutic Communities

27, no. 1 (2006): 147–58. 

Albornoz, Yadira. “The Effects of Group Improvisational Music Therapy on Depression in Adolescents and Adults 

with Substance Abuse: A Randomized Controlled Trial.” Nordic Journal of Music Therapy 20, no. 3 (2011): 208–24. 

Blackett, Peter S., and Helen L. Payne. “Health Rhythms: A Preliminary Inquiry into Group-Drumming as Experienced 

by Participants on a Structured Day Services Programme for Substance-Misusers.” Drugs: Education, Prevention and 

Policy 12, no. 6 (January 2005): 477–91.

Cevasco, Andrea M., Roy Kennedy, and Natalie Ruth Generally. “Comparison of Movement-to-Music, Rhythm 

Activities, and Competitive Games on Depression, Stress, Anxiety, and Anger of Females in Substance Abuse 

Rehabilitation.” Journal of Music Therapy 42, no. 1 (2005): 64–80. 

Correia, Ana Filipa, and Sofia Barbosa. “Cinema, Aesthetics and Narrative: Cinema as Therapy in Substance Use 

Disorders.” The Arts in Psychotherapy 60 (September 2018): 63–71.

Dickerson, Daniel, Kamilla L. Venner, Bonnie Duran, Jeffery J. Annon, Benjamin Hale, and George Funmaker. “DrumAssisted Recovery Therapy for Native Americans (DARTNA): Results from a Pretest and Focus Groups.” American 

Indian and Alaska Native Mental Health Research (Online) 21, no. 1 (2014): 35.

Dingle, Genevieve A., Libby Gleadhill, and Felicity A. Baker. “Can Music Therapy Engage Patients in Group Cognitive 

Behaviour Therapy for Substance Abuse Treatment?” Drug and Alcohol Review 27, no. 2 (2008): 190–96.

Fritz, Thomas Hans, Marius Vogt, Annette Lederer, Lydia Schneider, Eira Fomicheva, Martha Schneider, and Arno 

Villringer. “Benefits of Listening to a Recording of Euphoric Joint Music Making in Polydrug Abusers.” Frontiers in 

Human Neuroscience 9 (2015): 300.

Gardner, Paula J., and Jennifer M. Poole. “One Story at a Time: Narrative Therapy, Older Adults, and Addictions.” 

Journal of Applied Gerontology 28, no. 5 (October 2009): 600–20. 

Gardstrom, Susan C., and Wiebke S. Diestelkamp. “Women with Addictions Report Reduced Anxiety after Group 

Music Therapy: A Quasi-Experimental Study.” Voices: A World Forum for Music Therapy 13, no. 2 (2013). https://doi.

org/10.15845/voices.v13i2.681. 

Gardstrom, Susan C., Jacklyn Bartkowski, Joy Willenbrink, and Wiebke S. Diestelkamp. “The Impact of Group Music 

Therapy on Negative Affect of People with Co-occurring Substance Use Disorders and Mental Illnesses.” Music 

Therapy Perspectives 31, no. 2 (2013): 116–26.

Hill, John C., Bryan Hains, and Kristina Ricketts. “Drumming: An Innovative Alternative for Drug Addicted 

Individuals.” Journal of Alcohol and Drug Education 61, no. 2 (2017): 7–24. 

Hwang, Eun-Young, and Sun-Hwa Oh. “A Comparison of the Effects of Music Therapy Interventions on Depression, 

Anxiety, Anger, and Stress on Alcohol-Dependent Clients: A Pilot Study.” Music and Medicine 5, no. 3 (2013): 136–44. 
68 National Endowment for the Arts | arts.gov

Jones, Jennifer D. “A Comparison of Songwriting and Lyric Analysis Techniques to Evoke Emotional Change in a 

Single Session with People Who Are Chemically Dependent.” Journal of Music Therapy 42, no. 2 (2005): 94–110. 

Laurer, Mattye, and Renée van der Vennet. “Effect of Art Production on Negative Mood and Anxiety for Adults in 

Treatment for Substance Abuse.” Art Therapy 32, no. 4 (October 2015): 177–83. 

Morse, Nuala, Linda J.M. Thomson, Zoe Brown, and Helen J. Chatterjee. “Effects of Creative Museum Outreach 

Sessions on Measures of Confidence, Sociability and Well-Being for Mental Health and Addiction Recovery ServiceUsers.” Arts & Health 7, no. 3 (2015): 231–46. https://doi.org/10.1080/17533015.2015.1061570.

Murphy, Kathleen M. “The Effect of Group Guided Music and Imagery on the Psychological Health of Adults in 

Substance Abuse Treatment.” PhD diss., Temple University, 2008. 

Oklan, Ari M., and Sheila J. Henderson. “Treating Inhalant Abuse in Adolescence: A Recorded Music Expressive Arts 

Intervention.” Psychomusicology: Music, Mind, and Brain 24, no. 3 (2014): 231. 

Silverman, Michael J. “Effects of a Single Lyric Analysis Intervention on Withdrawal and Craving with Inpatients on a 

Detoxification Unit: A Cluster-Randomized Effectiveness Study.” Substance Use & Misuse 51, no. 2 (2016): 241–49. 

Silverman, Michael J. “Effects of Educational Music Therapy on Knowledge of Triggers and Coping Skills, Motivation, 

and Treatment Eagerness in Patients on a Detoxification Unit: A Three-Group Cluster-Randomized Effectiveness 

Study.” Korean Journal of Music Therapy 17, no. 2 (October 2015): 81–101.

Silverman, Michael J. “Effects of Group-Based Educational Songwriting on Craving in Patients on a Detoxification 

Unit: A Cluster-Randomized Effectiveness Study.” Psychology of Music 47, no. 2 (March 2019): 241–54. 

Silverman, Michael J. “Effects of Group Songwriting on Motivation and Readiness for Treatment on Patients in 

Detoxification: A Randomized Wait-List Effectiveness Study.” Journal of Music Therapy 49, no. 4 (2012): 414–29. 

Silverman, Michael J. “Effects of Live and Educational Music Therapy on Working Alliance and Trust with Patients on 

Detoxification Unit: A Four-Group Cluster-Randomized Trial.” Substance Use & Misuse 51, no. 13 (November 9, 2016): 

1741–50. 

Silverman, Michael J. “Effects of Lyric Analysis Interventions on Treatment Motivation in Patients on a Detoxification 

Unit: A Randomized Effectiveness Study.” Journal of Music Therapy 52, no. 1 (2015): 117–34. 

Silverman, Michael J. “Effects of Music Therapy on Change and Depression on Clients in Detoxification.” Journal of 

Addictions Nursing 22, no. 4 (December 2011): 185–92. 

Silverman, Michael J. “Effects of Music Therapy on Change Readiness and Craving in Patients on a Detoxification 

Unit.” Journal of Music Therapy 48, no. 4 (2011): 509–31. 

Silverman, Michael J. “Effects of Music Therapy on Drug Avoidance Self-Efficacy in Patients on a Detoxification Unit: 

A Three-Group Randomized Effectiveness Study.” Journal of Addictions Nursing 25, no. 4 (2014): 172–81. 

Silverman, Michael J. “Quantitative Comparison of Group-Based Music Therapy Experiences in Adults with 

Substance Use Disorder on a Detoxification Unit: A Three-Group Cluster-Randomized Study.” Arts & Health: An 

International Journal of Research, Policy and Practice (2019): 1-14. https://doi.org/10.1080/17533015.2019.1608568.

Silverman, Michael J. “Songwriting to Target State Shame, Guilt, and Pride in Adults with Substance Use Disorder on 

a Detoxification Unit: A Cluster-Randomized Study.” Substance Use & Misuse 54, no. 8 (July 2019): 1345–54. 

Silverman, Michael J. “The Effect of a Lyric Analysis Intervention on Withdrawal Symptoms and Locus of Control in 

Patients on a Detoxification Unit: A Randomized Effectiveness Study.” The Arts in Psychotherapy 37, no. 3 (July 2010): 

197–201. 
Arts Strategies for Addressing the Opioid Crisis: Examining the Evidence 69

Silverman, Michael J. “The Effect of Lyric Analysis on Treatment Eagerness and Working Alliance in Consumers 

Who Are in Detoxification: A Randomized Clinical Effectiveness Study.” Music Therapy Perspectives 27, no. 2 (2009): 

115–21.

Stamou, Vasileios, Theano Chatzoudi, Lelouda Stamou, Lucia Romo, and Pierluigi Graziani. “Music-Assisted 

Systematic Desensitization for the Reduction of Craving in Response to Drug-Conditioned Cues: A Pilot Study.” The 

Arts in Psychotherapy 51 (2016): 36–45.

Stamou, Vasileios, Rebecca Clerveaux, Lelouda Stamou, Sarah Le Rocheleuil, Lucie Berejnoi, Lucia Romo, and 

Pierluigi Graziani. “The Therapeutic Contribution of Music in Music-Assisted Systematic Desensitization for 

Substance Addiction Treatment: A Pilot Study.” The Arts in Psychotherapy 56 (2017): 30–44.

Testoni, Ines, Clara Cecchini, Maria Zulian, Maria Silvia Guglielmin, Lucia Ronconi, Kate Kirk, Flaviana Berto, Chiara 

Guardigli, and Ana Sofia Cruz. “Psychodrama in Therapeutic Communities for Drug Addiction: A Study of Four Cases 

Investigated Using Idiographic Change Process Analysis.” The Arts in Psychotherapy 61 (November 2018): 10–20.

Wasmuth, Sally, and Kevin Pritchard. “Theater-Based Community Engagement Project for Veterans Recovering from 

Substance Use Disorders.” The American Journal of Occupational Therapy 70, no. 4 (August 2016): 1–11. https://doi.

org/10.5014/ajot.2016.018333. 

Yun, Sung Hyun, and Wilfred Gallant. “Evidence-Based Clinical Practice: The Effectiveness of Music-Based 

Intervention for Women Experiencing Forgiveness/Grief Issues.” Journal of Evidence-Based Social Work 7, no. 5 

(November 2010): 361–76.
70 National Endowment for the Arts | arts.gov

Page 

intentionally 

blank
Arts Strategies for Addressing the Opioid Crisis: Examining the Evidence 71

Appendix B. Literature Review Methodology

Search Strategy

The search for relevant literature was completed in four steps:

1. Researchers searched publication databases using a combination of search terms (see next section for 

search terms): 

• MEDLINE

• PsycARTICLES

• Psychology and Behavioral Sciences Collection

• PsycINFO

• SocINDEX

• Sociology Source Ultimate

• CINAHL

• Arts and Humanities Citation Index

2. Researchers performed backward and forward reference searches, or identified and retrieved additional 

sources, including gray and white literature, by following chains of citations and sources identified as a result 

of the initial search. For example, the reference sections of all publications retrieved were examined to 

identify potentially relevant articles and reports. In addition, “forward snowballing” was performed to see if 

included articles were cited by relevant published articles.

3. Researchers identified and retrieved additional sources from the program scan, such as published or 

unpublished findings from a featured program. 

4. Researchers obtained sources and materials suggested by the TWG members and the National Endowment 

for the Arts. For instance, table of contents searches of select journals were conducted. 

Search Terms

Search terms were developed using the PICO (population, intervention, comparison, outcome) framework.aj

Researchers worked with the National Endowment for the Arts and the TWG to populate additional search terms 

(within the columns in Exhibits B1–B3) to capture use of different terminology (e.g., pain reduction versus pain 

management) and variations in the specific outcomes measured under the broad outcome domains of prevention 

and treatment. A combination of Medical Subject Headings (MeSH) searching, keyword searching, and text word 

searching was used. Searches were refined by limiting text word searching to titles. 

Exhibits B1–B3 present search terms for each research question. Relevant citations yielded through the search were 

managed using Zotero reference management software to prevent duplicate citations and allow easy access and 

management of citations and abstracts. 

aj For more information, see Karen Sue Davies, “Formulating the Evidence Based Practice Question: A Review of the Frameworks,” Evidence 

Based Library and Information Practice 6, no. 2 (2011): 75–80.
72 National Endowment for the Arts | arts.gov

Publication database searches were limited to peer-reviewed sources. White or gray literature, including 

unpublished dissertations or theses, was not systematically searched for. However, white and gray literature that 

was identified through backward and forward reference searches (i.e., following chains of citations and sources 

identified as a result of the initial search) was reviewed.

Eligibility Criteria 

Abstracts from studies identified using the above search methods and terms were screened with the following 

inclusion criteria:

1. The intervention or program emphasized use of the arts to manage pain or to prevent or treat SUD;

2. The intervention or program had a goal of managing pain or preventing or treating SUD;

3. The article discussed outcomes specific to managing pain or preventing or treating SUD;

4. The article was published in English; and

5. The article was published between January 1999 and July 2019. 

Abstracts were also screened for the following exclusion criterion: study sample did not represent the target 

population (i.e., individuals at risk for OUD or other SUD). For example, studies of palliative care patients and 

young children, including studies of infants with neonatal abstinence syndrome, were excluded. In addition, pain 

management studies were excluded if the sample was not a clinical population (e.g., experimentally induced pain). 

SUD literature was excluded if the target was tobacco cessation.
Arts Strategies for Addressing the Opioid Crisis: Examining the Evidence 73

Exhibit B1. Search Terms for Arts-Based Programs and Pain Management

Population Intervention Outcome

Chronic pain

OR 

Acute pain

OR

Clinical pain

Or

Procedural 

pain

OR

Phantom pain

OR

Neuropathic 

pain 

art OR arts OR artist OR artists OR artistic OR artistry OR artistries OR quilt 

OR quilting OR quilts OR quilted OR chalk OR “TV” OR stamp OR stamping 

OR stamps OR origami OR needlework OR stitchery OR woodwork OR 

woodworking OR woodturning OR “basket making” OR “basket weaving” OR 

batik OR batiks OR calligraphy OR calligraphic OR carve OR carves OR carved 

OR carving OR sketch OR sketches OR sketching OR illustration* OR enamel 

OR enamels OR enameling OR engrave OR engraves OR engraved OR engraving 

OR gardening OR landscape OR landscapes OR landscaping OR landscaped OR 

ikebana OR bonsai OR “floral arrangement” OR “floral arrangements” OR “floral 

arranging” OR “flower arrangement” OR “flower arrangements” OR “flower 

arranging” OR lithograph* OR printmak* OR “print making” OR “print maker” 

OR “print makers” OR “silk screen” OR “silk screens” OR “silk screened” OR 

“silk screening” OR “jewelry making” OR weaving OR woven OR metalwork* 

OR “metal work” OR “metal working” OR “tin smithing” OR “silver smithing” OR 

blacksmithing OR acting OR playwriting OR “writing plays” OR “play writer” 

OR “play write” OR “play writing” OR jazz OR “art based” OR “arts based” OR 

“creative effort” OR “creative efforts” OR “creative engagement” OR “creative 

expression” OR “creative expressions” OR “creative medicine” OR “creative 

practice” OR “creative therapy” OR “creative therapies” OR “creative writing” 

OR “diary writing” OR diaries OR “emotional writing” OR “group writing” OR 

“entertainment education” OR “expressive activity” OR “expressive activities” 

OR “expressive writing” OR “graphic novel” OR “graphic novels” OR “graphic 

representation” OR “graphic representations” OR “health humanities” OR 

“journal writing” OR “medical humanities” OR “movement expression” OR 

“movement expressions” OR “movement therapy” OR “movement therapies” 

OR “narrative medicine” OR “passive listening” OR “play space” OR “play spaces” 

OR “role play” OR “role playing” OR “role plays” OR acrylics OR animation* OR 

artwork* OR ballet OR caricature OR caricatures OR cartoon* OR chants OR 

chanting OR choir OR choreography OR choreographing OR choreographe* 

OR clay OR collag* OR comic OR comics OR comicbook* OR danc* OR drama* 

OR drawing* OR edutainment OR etching* OR film OR films OR filming OR 

filmed OR fotonovela* OR photonovella* OR handicraft* OR crafts OR crafting 

OR imaginative OR improvisation* OR journaling OR mandala* OR mural* 

OR museum* OR music* OR novela* OR novella* OR opera* OR paint* OR 

photograph* OR photovoice OR “photo voice” OR pictorial OR plays OR poet* 

OR poem* OR portrait* OR pottery OR puppet* OR radio OR rap OR raps OR 

rapping OR sandplay* OR sculpt* OR sing OR singing OR skit OR skits OR 

song* OR story OR stories OR storyline* OR storytell* OR essay OR essays 

OR television OR textiles OR theatr* OR theater* OR transmedia OR vlog* OR 

watercolor* OR “water color” OR “water colors” OR “water colour” OR “water 

colours” OR watercolour* OR youtube OR “you tube” OR movie* OR cinema 

OR ceramics OR imagery OR mosaic* OR lyrics OR graffiti OR “hip hop” OR 

aesthetic* OR esthetic* OR “glass blowing” OR “glass fusing” OR knitting OR 

“rug hooking” OR crochet* 

NOT (antiretroviral OR “anti retroviral” OR “HAART” OR “assisted reproductive 

therap*” OR “state of the art”)

Pain

OR

Pain 

management

OR

Pain perception

OR

Pain 

measurement

OR

Health 

promotion

OR

Well-being

OR

Quality of life
74 National Endowment for the Arts | arts.gov

Exhibit B2. Search Terms for Arts-Based Programs and Substance Use Disorder Prevention

Population Intervention Outcome

Adolescents

OR

Youth

OR

Adults

art OR arts OR artist OR artists OR artistic OR artistry OR artistries OR quilt 

OR quilting OR quilts OR quilted OR chalk OR “TV” OR stamp OR stamping 

OR stamps OR origami OR needlework OR stitchery OR woodwork OR 

woodworking OR woodturning OR “basket making” OR “basket weaving” 

OR batik OR batiks OR calligraphy OR calligraphic OR carve OR carves OR 

carved OR carving OR sketch OR sketches OR sketching OR illustration* OR 

enamel OR enamels OR enameling OR engrave OR engraves OR engraved 

OR engraving OR gardening OR landscape OR landscapes OR landscaping 

OR landscaped OR ikebana OR bonsai OR “floral arrangement” OR “floral 

arrangements” OR “floral arranging” OR “flower arrangement” OR “flower 

arrangements” OR “flower arranging” OR lithograph* OR printmak* OR 

“print making” OR “print maker” OR “print makers” OR “silk screen” OR “silk 

screens” OR “silk screened” OR “silk screening” OR “jewelry making” OR 

weaving OR woven OR metalwork* OR “metal work” OR “metal working” 

OR “tin smithing” OR “silver smithing” OR blacksmithing OR acting OR 

playwriting OR “writing plays” OR “play writer” OR “play write” OR “play 

writing” OR jazz OR “art based” OR “arts based” OR “creative effort” OR 

“creative efforts” OR “creative engagement” OR “creative expression” 

OR “creative expressions” OR “creative medicine” OR “creative practice” 

OR “creative therapy” OR “creative therapies” OR “creative writing” OR 

“diary writing” OR diaries OR “emotional writing” OR “group writing” 

OR “entertainment education” OR “expressive activity” OR “expressive 

activities” OR “expressive writing” OR “graphic novel” OR “graphic novels” 

OR “graphic representation” OR “graphic representations” OR “health 

humanities” OR “journal writing” OR “medical humanities” OR “movement 

expression” OR “movement expressions” OR “movement therapy” OR 

“movement therapies” OR “narrative medicine” OR “passive listening” OR 

“play space” OR “play spaces” OR “role play” OR “role playing” OR “role 

plays” OR acrylics OR animation* OR artwork* OR ballet OR caricature OR 

caricatures OR cartoon* OR chants OR chanting OR choir OR choreography 

OR choreographing OR choreographe* OR clay OR collag* OR comic OR 

comics OR comicbook* OR danc* OR drama* OR drawing* OR edutainment 

OR etching* OR film OR films OR filming OR filmed OR fotonovela* OR 

photonovella* OR handicraft* OR crafts OR crafting OR imaginative OR 

improvisation* OR journaling OR mandala* OR mural* OR museum* OR 

music* OR novela* OR novella* OR opera* OR paint* OR photograph* OR 

photovoice OR “photo voice” OR pictorial OR plays OR poet* OR poem* 

OR portrait* OR pottery OR puppet* OR radio OR rap OR raps OR rapping 

OR sandplay* OR sculpt* OR sing OR singing OR skit OR skits OR song* 

OR story OR stories OR storyline* OR storytell* OR essay OR essays OR 

television OR textiles OR theatr* OR theater* OR transmedia OR vlog* 

OR watercolor* OR “water color” OR “water colors” OR “water colour” OR 

“water colours” OR watercolour* OR youtube OR “you tube” OR movie* OR 

cinema OR ceramics OR imagery OR mosaic* OR lyrics OR graffiti OR “hip 

hop” OR aesthetic* OR esthetic* OR “glass blowing” OR “glass fusing” OR 

knitting OR “rug hooking” OR crochet* 

NOT (antiretroviral OR “anti retroviral” OR “HAART” OR “assisted 

reproductive therap*” OR “state of the art”)

Opioid use

OR

Substance use

OR

Substance abuse

OR

Addiction

OR

Alcoholism

OR

Amphetamine use

OR

Cocaine use

OR

Cannabis use

OR

Hallucinogens use

OR

Phencyclidine use

OR

Inhalants use

OR

Sedatives use

OR

Hypnotics use

OR

Anxiolytics use

OR

Abstinence

OR

Depression

OR 

Depressive symptoms

OR

Anxiety

OR 

Juvenile delinquency

OR

Delinquent behavior 

OR

Educational attainment

OR

Academic performance

OR

Positive youth development

OR

Social support

OR

Prosocial peers

OR

Prosocial activities
Arts Strategies for Addressing the Opioid Crisis: Examining the Evidence 75

Exhibit B3. Search Terms for Arts-Based Programs and Substance Use Disorder Treatment

Population Intervention Outcome

Opioid use disorder

OR

Opioid dependency

OR

Opioid-related 

disorders

OR

Opiates

OR

Opiate substitution 

treatment

OR

Heroin dependency

OR

Heroin addiction

OR

Drug abuse

OR

Drug dependency

OR

Substance use 

disorder

OR

Substance use 

treatment

OR

Substance abuse

OR

Addiction

OR

Chemical 

dependency

art OR arts OR artist OR artists OR artistic OR artistry OR artistries 

OR quilt OR quilting OR quilts OR quilted OR chalk OR “TV” OR stamp 

OR stamping OR stamps OR origami OR needlework OR stitchery OR 

woodwork OR woodworking OR woodturning OR “basket making” OR 

“basket weaving” OR batik OR batiks OR calligraphy OR calligraphic 

OR carve OR carves OR carved OR carving OR sketch OR sketches OR 

sketching OR illustration* OR enamel OR enamels OR enameling OR 

engrave OR engraves OR engraved OR engraving OR gardening OR 

landscape OR landscapes OR landscaping OR landscaped OR ikebana 

OR bonsai OR “floral arrangement” OR “floral arrangements” OR “floral 

arranging” OR “flower arrangement” OR “flower arrangements” OR 

“flower arranging” OR lithograph* OR printmak* OR “print making” OR 

“print maker” OR “print makers” OR “silk screen” OR “silk screens” OR 

“silk screened” OR “silk screening” OR “jewelry making” OR weaving 

OR woven OR metalwork* OR “metal work” OR “metal working” OR 

“tin smithing” OR “silver smithing” OR blacksmithing OR acting OR 

playwriting OR “writing plays” OR “play writer” OR “play write” OR “play 

writing” OR jazz OR “art based” OR “arts based” OR “creative effort” OR 

“creative efforts” OR “creative engagement” OR “creative expression” 

OR “creative expressions” OR “creative medicine” OR “creative practice” 

OR “creative therapy” OR “creative therapies” OR “creative writing” OR 

“diary writing” OR diaries OR “emotional writing” OR “group writing” 

OR “entertainment education” OR “expressive activity” OR “expressive 

activities” OR “expressive writing” OR “graphic novel” OR “graphic novels” 

OR “graphic representation” OR “graphic representations” OR “health 

humanities” OR “journal writing” OR “medical humanities” OR “movement 

expression” OR “movement expressions” OR “movement therapy” OR 

“movement therapies” OR “narrative medicine” OR “passive listening” OR 

“play space” OR “play spaces” OR “role play” OR “role playing” OR “role 

plays” OR acrylics OR animation* OR artwork* OR ballet OR caricature 

OR caricatures OR cartoon* OR chants OR chanting OR choir OR 

choreography OR choreographing OR choreographe* OR clay OR collag* 

OR comic OR comics OR comicbook* OR danc* OR drama* OR drawing* 

OR edutainment OR etching* OR film OR films OR filming OR filmed OR

fotonovela* OR photonovella* OR handicraft* OR crafts OR crafting OR 

imaginative OR improvisation* OR journaling OR mandala* OR mural* 

OR museum* OR music* OR novela* OR novella* OR opera* OR paint* OR 

photograph* OR photovoice OR “photo voice” OR pictorial OR plays OR 

poet* OR poem* OR portrait* OR pottery OR puppet* OR radio OR rap 

OR raps OR rapping OR sandplay* OR sculpt* OR sing OR singing OR skit 

OR skits OR song* OR story OR stories OR storyline* OR storytell* OR 

essay OR essays OR television OR textiles OR theatr* OR theater* OR 

transmedia OR vlog* OR watercolor* OR “water color” OR “water colors” 

OR “water colour” OR “water colours” OR watercolour* OR youtube OR 

“you tube” OR movie* OR cinema OR ceramics OR imagery OR mosaic* 

OR lyrics OR graffiti OR “hip hop” OR aesthetic* OR esthetic* OR “glass 

blowing” OR “glass fusing” OR knitting OR “rug hooking” OR crochet* 

NOT (antiretroviral OR “anti retroviral” OR “HAART” OR “assisted 

reproductive therap*” OR “state of the art”)

Substance use

OR

Substance abuse

OR

Drug abuse

OR

Opioid use

OR

Amphetamine

OR

Cocaine

OR

Cannabis

OR

Hallucinogens

OR

Phencyclidine

OR

Inhalants

OR

Sedatives

OR

Hypnotics

OR

Anxiolytics

OR

Abstinence

OR

Drug avoidance

OR

Withdrawal

OR

Craving

OR 

Depression

OR

Depressive symptoms

OR

Anxiety

OR

Motivation

OR

Participation

OR

Coping skills

OR

Healing

OR

Recovery
76 National Endowment for the Arts | arts.gov

Abstract Review 

A team of four researchers was trained on the inclusion/exclusion criteria. Then, using Covidence (an online abstract 

screening software), two researchers independently reviewed each abstract identified through the search process 

and coded it for inclusion or exclusion based on the eligibility criteria. In cases of disagreement, researchers met to 

reach a consensus. 

The search and review process ended in a total of 116 articles eligible for inclusion in the final report (for a full list of 

included articles, see appendix A). 

The initial search yielded 879 abstracts, of which 79 were eligible for full text review and 51 were eligible for 

inclusion in the final report (see Exhibit B4). 

Exhibit B4. Search Process

The reference sections of the first 51 articles were then reviewed to identify additional potentially relevant articles 

and reports. 

Researchers also performed a table of contents search for four journals that are not indexed by publication 

databases but that were believed to have relevant literature and encompass a wide range of art forms:

1. The Arts in Psychotherapy

2. Art Therapy: Journal of the American Art Therapy Association

3. Arts & Health

4. Voices: The Art and Science of Psychotherapy

The first snowball search and table of contents search resulted in 22 and 11 articles, respectively. A second snowball 

search was then performed on these 33 articles.

Initial Search

N = 879 (97 duplicates)

Snowball Search

First 51 articles

Table of Contents 

Search

Snowball Search

Next 33 articles

116 articles eligible

for inclusion

Records after duplicates

(n = 782)

Records screened

(n = 782)

Records eligible for full 

text review

(n = 79)

36 articles eligible for

full text review

13 articles eligible for

full text review

51 articles eligible for

full text review

Records eligible for 

inclusion

(n = 51)

22 articles eligible

for inclusion

11 articles eligible

for inclusion

32 articles eligible

for inclusion

Records excluded based on 

full text review (n = 63)

Reasons for exclusion:

• Irrelevant intervention: 19

• Irrelevant population: 11

• No outcomes measured: 10

• Irrelevant outcomes: 8

• Poster: 5

• No access: 5

• Non-English: 2

• Duplicate: 3

Records excluded based on 

abstract review (n = 731)

Reasons* for exclusion:

• Irrelevant intervention: 437

• Irrelevant outcomes: 218

• No outcomes measured: 206

• Irrelevant population: 92

• Non-English: 23

• Book: 2

* Not mutually exclusive
Arts Strategies for Addressing the Opioid Crisis: Examining the Evidence 77

Data Abstraction

A team of four researchers was trained on the data abstraction process. Full text articles selected for inclusion were 

independently reviewed and coded to abstract necessary data (see Exhibit B5). If the study did not include all the 

information listed, the information was listed as unavailable and reported as a missing element. 

Exhibit B5. Data Abstraction Categories

Intervention 

characteristics

• Name of program, curriculum, or intervention

• Funding source

• Location

• Theoretical model/framework

• Targeted outcome areas/goals

• Intended content and activities

• Format (e.g., music, arts)

• Program format (group versus individual)

• Medium-specific characteristics (e.g., for music: music characteristics; participant 

selected versus researcher selected)

• Intended frequency and length of services

• Staffing/intervener characteristics 

Study 

methodology

• Study design

• Internal validity

• Sample size

• Data collection methods

• Primary and secondary outcomes, where relevant

Participant 

characteristics

• Age

• Gender

• Race/ethnicity

Outcomes

• Results related to pain or substance use disorders

• Results from subgroup analyses

• Effect sizes, if reported

Future 

directions

• Study limitations

• Implications

Mixed Methods Appraisal Tool

The Mixed Methods Appraisal Tool (MMAT) was used to appraise and describe the empirical studies included in 

the literature review. The MMAT includes five individual checklists, one each for qualitative studies, quantitative 

randomized control trials, quantitative nonrandomized studies, quantitative descriptive studies, and mixed methods 

studies. Each checklist includes five design-specific quality criteria and guidance for appraising the presence or 

absence of each item. 
78 National Endowment for the Arts | arts.gov

The MMAT was reviewed by the National Collaborating Centre for Methods and Tools (NCCMT) as well-suited 

to public health contexts, particularly for questions related to complex interventions that are context dependent 

and process oriented.ak MMAT instructions for summarizing results align with the increasing shift in the research 

community to move away from scoring individual studies or using composite scores to appraise evidence.al The tool 

has been validated in several studies testing its interrater reliability, usability, and content validity and was most 

recently updated in 2018.am

Researchers were trained on the MMAT user guide and met routinely to discuss any disagreements in appraisals. 

Detailed MMAT results for each research question are reported in appendix C.

Validity Checks

Researchers were trained to independently and reliably abstract data using a standardized form and process and to 

apply the MMAT. To ensure continued accuracy, a second reviewer reviewed, abstracted, and applied the MMAT to 

10 percent of studies. 

ak For more information, see NCCMT Registry at http://www.nccmt.ca/resources/search/23

al For more information, see Mary Dixon-Woods et al., “Appraising Qualitative Research for Inclusion in Systematic Reviews: A Quantitativ

and Qualitative Comparison of Three Methods,” Journal of Health Services & Research Policy 12 (2007): 42–47. 

am For more information, see Quan Nha Hong et al., Mixed Methods Appraisal Tool (MMAT), version 2018. Registration of Copyrigh

(#1148552), Canadian Intellectual Property Office, Industry Canada.
Arts Strategies for Addressing the Opioid Crisis: Examining the Evidence 79

Appendix C. Mixed Methods Appraisal Tool 

Results

The MMAT includes five individual checklists, one each for qualitative studies, quantitative randomized control 

trials, quantitative nonrandomized studies, quantitative descriptive studies, and mixed methods studies. Each 

checklist includes five design-specific quality criteria and guidance for appraising the presence or absence of each 

item. Exhibits C1 and C2 present aggregate checklist items for all pain management and all SUD treatment studies, 

respectively. Results from the single SUD prevention study are not included because this information could not be 

reported in aggregate.

Exhibit C1. Mixed Methods Appraisal Tool Checklist Overview for Pain Management Studies

% Yes % No % Can’t 

tell

Qualitative (n=1)

Is the qualitative approach appropriate to answer the research question? 100

Are the qualitative data collection methods adequate to address the 

research question?

100

Are the findings adequately derived from the data? 100

Is the interpretation of results sufficiently substantiated by data? 100

Is there coherence between qualitative data sources, collection, analysis 

and interpretation?

100

Quantitative randomized controlled trials (n=54)

Is randomization appropriately performed? 74 7 19

Are the groups comparable at baseline? 83 4 13

Are there complete outcome data? 87 7 6

Are outcome assessors blinded to the intervention provided? 0 100 0

Did the participants adhere to the assigned intervention? 94 4 2

Quantitative non-randomized (n=15)

Are the participants representative of the target population? 100 0 0

Are measurements appropriate regarding both the outcome and 

intervention (or exposure)?

100 0 0

Are there complete outcome data? 87 13 0

Are the confounders accounted for in the design and analysis? 40 20 40

During the study period, is the intervention administered (or exposure 

occurred) as intended?

87 13 0
80 National Endowment for the Arts | arts.gov

% Yes % No % Can’t 

tell

Quantitative Descriptive (n=2)

Is the sampling strategy relevant to address the research question? 50 0 50

Is the sample representative of the target population? 50 50 0

Are the measurements appropriate? 100 0 0

Is the risk of nonresponse bias low? 50 50 0

Is the statistical analysis appropriate to answer the research question? 100 0 0

Mixed Methods (n=7)

Is there an adequate rationale for using a mixed methods design to address 

the research question?

100 0 0

Are the different components of the study effectively integrated to answer 

the research question?

100 0 0

Are the outputs of the integration of qualitative and quantitative 

components adequately interpreted?

100 0 0

Are divergences and inconsistencies between quantitative and qualitative 

results adequately addressed?

86 0 14

Do the different components of the study adhere to the quality criteria of 

each tradition of the methods involved?

86 14 0

Exhibit C2. Mixed Methods Appraisal Tool Checklist Overview for Substance Use Disorder 

Treatment Studies

% Yes % No % Can’t 

tell

Qualitative (n=2)

Is the qualitative approach appropriate to answer the research question? 100 0 0

Are the qualitative data collection methods adequate to address the 

research question?

100 0 0

Are the findings adequately derived from the data? 100 0 0

Is the interpretation of results sufficiently substantiated by data? 50 0 50

Is there coherence between qualitative data sources, collection, analysis, 

and interpretation?

50 0 50

Quantitative randomized controlled trials (n=18)

Is randomization appropriately performed? 89 0 11

Are the groups comparable at baseline? 83 11 6

Are there complete outcome data? 89 11 0

Are outcome assessors blinded to the intervention provided? 0 100 0

Did the participants adhere to the assigned intervention? 100 0 0
Arts Strategies for Addressing the Opioid Crisis: Examining the Evidence 81

% Yes % No % Can’t 

tell

Quantitative non-randomized (n=9)

Are the participants representative of the target population? 100 0 0

Are measurements appropriate regarding both the outcome and 

intervention (or exposure)?

78 11 11

Are there complete outcome data? 78 11 11

Are the confounders accounted for in the design and analysis? 56 44 0

During the study period, is the intervention administered (or exposure 

occurred) as intended?

100 0 0

Quantitative Descriptive (n=2)

Is the sampling strategy relevant to address the research question? 50 0 50

Is the sample representative of the target population? 100 0 0

Are the measurements appropriate? 100 0 0

Is the risk of nonresponse bias low? 100 0 0

Is the statistical analysis appropriate to answer the research question? 100 0 0

Mixed Methods (n=5)

Is there an adequate rationale for using a mixed methods design to address 

the research question?

100 0 0

Are the different components of the study effectively integrated to answer 

the research question?

100 0 0

Are the outputs of the integration of qualitative and quantitative 

components adequately interpreted?

100 0 0

Are divergences and inconsistencies between quantitative and qualitative 

results adequately addressed?

100 0 0

Do the different components of the study adhere to the quality criteria of 

each tradition of the methods involved?

80 0 20
82 National Endowment for the Arts | arts.gov

Page 

intentionally 

blank
Arts Strategies for Addressing the Opioid Crisis: Examining the Evidence 83

Appendix D. Program Scan Methodology

Search Strategy

An initial list of candidate programs was generated through a search of electronic resources (i.e., federal agency 

websites, publication databases, and website search engines) using search terms based on those used in the 

literature search (e.g., “art therapy,” “art education,” “pain management,” “SUD,” “OUD”). The federal agency websites 

and search engines used are listed in Exhibit D1. Search terms are listed in Exhibits D2–D5. Additional programs 

were also added on the recommendation of the National Endowment for the Arts and the TWG.

Exhibit D1. Federal Agency Websites and Search Engines

Agency name

Substance Abuse and Mental Health Services Administration (i.e., Substance Abuse Treatment Facility Locator)

National Institute on Drug Abuse

Office of Disease Prevention and Health Promotion

Office of Juvenile Justice and Delinquency Prevention—Model Programs Guide; literature review on Arts-Based 

Programs for Youth

U.S. Department of Health and Human Services

National Institute of Justice—Program and Practice ratings (drugs and crime)

Youth.gov—Program Directory

National Organization for Arts and Health

University of Florida Health Shands/Arts in Medicine
84 National Endowment for the Arts | arts.gov

Exhibit D2. Search Terms for Arts Programs and Pain

Population Intervention Outcome

Chronic pain

OR 

Acute pain

OR

Clinical pain

Or

Procedural pain

OR

Veterans

Arts programming

OR

Community arts

OR

Music 

OR

Dance 

OR

Theater

OR 

Theatre

OR

Drama

OR

Poetry

OR

Expressing writing

OR

Journaling

OR

Storytelling

OR

Visual art

Pain
Arts Strategies for Addressing the Opioid Crisis: Examining the Evidence 85

Exhibit D3. Search Terms for Creative Arts Therapies and Pain

Population Intervention Outcome

Chronic pain

OR 

Acute pain

OR

Clinical pain

Or

Procedural pain

OR

Veterans

Art therapy

OR 

Music therapy

OR

Dance therapy

OR

Dance/Movement therapy

OR

Theater therapy

OR

Theatre therapy

OR

Drama therapy

OR

Drama psychotherapy

OR

Creative arts therapies

Pain 
86 National Endowment for the Arts | arts.gov

Exhibit D4. Search Terms for Arts Programs and Substance Use Disorder

Population Intervention Outcome

Opioid

OR

Opioids

OR

Substance use disorder

OR

Addiction

OR

Alcohol use disorder

OR

Alcoholism

OR

Veterans

OR

Rural communities

OR

Incarceration

OR

Juvenile justice system

Arts education

OR

Arts programming

OR

Community arts

OR

Music 

OR

Dance 

OR

Theater

OR 

Theatre

OR

Drama

OR

Poetry

OR

Expressing writing

OR

Journaling

OR

Storytelling

OR

Visual art

Opioid use

OR

Drug avoidance

OR

Withdrawal

OR

Craving

OR 

Motivation

OR

Participation

OR

Helpfulness

OR

Coping skills

OR

Depression

OR

Anxiety
Arts Strategies for Addressing the Opioid Crisis: Examining the Evidence 87

Exhibit D5. Search Terms for Creative Arts Therapies and Substance Use Disorder

Population Intervention Outcome

Opioid

OR

Opioids

OR

Substance use disorder

OR

Addiction

OR

Alcohol use disorder

OR

Alcoholism

OR

Veterans

OR

Rural communities

OR

Incarceration

OR

Juvenile justice system

Art therapy

OR 

Music therapy

OR

Dance therapy

OR

Dance/Movement therapy

OR

Theater therapy

OR

Theatre therapy

OR

Drama therapy

OR

Drama psychotherapy

OR

Creative arts therapies

Opioid use

OR

Drug avoidance

OR

Withdrawal

OR

Craving

OR 

Motivation

OR

Participation

OR

Helpfulness

OR

Coping skills

OR

Depression

OR

Anxiety 
88 National Endowment for the Arts | arts.gov

Eligibility Criteria 

Fifty programs identified using the above search methods were screened for inclusion using the criteria outlined in 

Exhibit D6. 

Exhibit D6. Criteria for Initial Inclusion

Criteria areas Criteria indicators

Arts focus • Based on the arts or has prominent components that include 

the arts as reflected by explicit use of keywords in title/name or 

published program description

Pain management or SUD prevention 

of treatment focus

• Centers on pain management or SUD prevention or treatment as 

reflected by explicit use of keywords in title/name or published 

program description

Recent or active implementation • Active or recently implemented (i.e., within the past five years)

Publicly available information • Information needed to review eligibility criteria is publicly 

available. 

Outcomes supported by some evidence • Evidence related to program outcomes is available.

Of the 50 programs, eight were eligible for inclusion. Programs included in the scan are listed in the program scan 

chapter. Programs that were not eligible for inclusion are listed in appendix E.

Data Abstraction

Researchers populated templates summarizing key information (e.g., lead agency or implementer, funding agency 

or mechanism, target areas, evaluation findings) for each program using a two-step process. First, publicly available 

information was reviewed and abstracted. Next, program representatives were contacted by a researcher to 

supplement information populated in the first step. 
Arts Strategies for Addressing the Opioid Crisis: Examining the Evidence 89

Appendix E. List of Additional Programs for 

Consideration

Several interesting and innovative arts-based programs were identified during the initial search for program scan 

candidates and suggested by TWG members. Exhibit E1 presents those programs that did not meet the criteria for 

inclusion in this report. 

Exhibit E1. Programs for Consideration

Program name

A Place Called Home—Creative Arts and Expression Program

Addiction Performance Project

Adriana Marchione—therapist, teacher, artist, trainer

Anchor Hospital Campus of Southern Crescent Behavioral Health System

Art and Addiction: Putting a Human Face on Addiction and Recovery

Art of Hope

Art of Rancho at Rancho Los Amigos 

Art Therapy at Mariners Inn

Art Therapy at St. John Ascension Brighton Recovery Center

Arts for Incarcerated Youth Network 

Arts for Life

Boys and Girls Club of the Los Angeles Harbor—Arts Academy

C.A.R.E. (Continuous Ambient Relaxation Environment)

Creative Forces: National Endowment for the Arts Military Healing Arts Network

Culture of Recovery

Dancing with Pain 

English Mountain Recovery Program

Face the Music Foundation

Harford County Office of Drug Control Policy 

Music Therapy Program at Creative Arts Therapies of the Palm Beaches

Music Therapy Program at Tallahassee Memorial HealthCare

New Hampshire Theatre Project Elephant in the Room Series

New York Writers Coalition 

Northbound Treatment Center 

NQP PlaybookTM: Opioid Stewardship 

Opioid Safe-Prescribing Training Immersion Program
90 National Endowment for the Arts | arts.gov

Program name

Pablove Shutterbugs

PAIN Exhibit Inc.

Partnership for a Drug-Free New Jersey—Heroin and Opioid Art Exhibition

Project Venture

R Creative Collective

Reading for Life

Rock to Recovery

Skyland Trail 

Snow City Arts

Somos La Arte 

Split This Rock 

St. Joseph’s Health—Alternatives to Opiates Program

The Bluffs Rehab—Ohio Heroin and Opioid Addiction Treatment Program

Therapeutic Music Program at Vista Del Mar

UCLA Music Partnership Program

YWCA Pasadena/Foothill Valley—Express Yourself!
Arts Strategies for Addressing the Opioid Crisis: Examining the Evidence 91

Endnotes

1 U.S. Department of Health and Human Services, “HHS Acting Secretary Declares Public Health Emergency to 

Address National Opioid Crisis,” HHS.gov, October 26, 2017, https://www.hhs.gov/about/news/2017/10/26/hhsacting-secretary-declares-public-health-emergency-address-national-opioid-crisis.html.

2 Heather L. Stuckey and Jeremy Nobel, “The Connection between Art, Healing, and Public Health: A Review of 

Current Literature,” American Journal of Public Health 100, no. 2 (2010): 254–63.

3 Anita Jense and Lars Ole Bonde, “The Use of Arts Interventions for Mental Health and Wellbeing in Health 

Settings,” Perspectives in Public Health 138, no. 4 (2018): 209–14.

4 Stuckey and Nobel, “Connection.”

5 Jense and Ole Bonde, “Use of Arts Interventions.”

6 Bern Heath, Pam Wise Romero, and Kathy Reynolds, A Review and Proposed Standard Framework for Levels of 

Integrated Healthcare (Washington, DC: SAMHSA-HRSA Center for Integrated Health Solutions, March 2013).

7 U.S. Department of Health and Human Services, “Facing Addiction in America: The Surgeon General’s Spotlight 

on Opioids,” Office of the Surgeon General, Washington, DC, 2018.

8 National Academies of Sciences, Engineering, and Medicine, “Pain Management and the Opioid Epidemic: 

Balancing Societal and Individual Benefits and Risks of Prescription Opioid Use,” National Academies Press, 

Washington D.C., 2017.

9 Teresa A. Rummans, M. Caroline Burton, and Nancy L. Dawson, “How Good Intentions Contributed to Bad 

Outcomes: The Opioid Crisis,” Mayo Clinic Proceedings 93, no. 3 (2018): 344–50.

10 Andrew Kolodny et al., “The Prescription Opioid and Heroin Crisis: A Public Health Approach to an Epidemic of 

Addiction,” Annual Review of Public Health 36 (2015): 559–74.

11 Heather Tick et al., “Evidence-Based Nonpharmacologic Strategies for Comprehensive Pain Care: The 

Consortium Pain Task Force White Paper,” Explore 14, no. 3 (2018): 177–211.

12 Assistant Secretary for Health (ASH), “Pain Management Task Force Issues Final Report on Best Practices for 

Treatment of Pain,” HHS.gov, May 30, 2019, https://www.hhs.gov/about/news/2019/05/30/pain-managementtask-force-issues-final-report-on-best-practices-for-treatment-of-pain.html.

13 U.S. Department of Health and Human Services, “Facing Addiction in America.”

14 U.S. Department of Health and Human Services, “HHS Acting Secretary.”

15 Stuckey and Nobel, “Connection.”

16 Jense and Ole Bonde, “Use of Arts Interventions.”

17 Heath et al., Framework for Levels of Integrated Healthcare.

18 Barbara Ganim, Art and Healing: Using Expressive Art to Heal Your Body, Mind, and Spirit (New York: Three Rivers 

Press, 1999).
92 National Endowment for the Arts | arts.gov

19 State of the Field Committee, State of the Field Report: Arts in Healthcare 2009 (Washington, DC: Society for the 

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20 George L. Engel, “The Need for a New Medical Model: A Challenge for Biomedicine,” Science 196, no. 4286 

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21 Stuckey and Nobel, “Connection.”

22 Jensen and Ole Bonde, “Use of Arts Interventions.”

23 Stuckey and Nobel, “Connection.”

24 Jill Sonke et al., “The State of the Arts in Healthcare in the United States,” Arts & Health 1, no. 2 (2009): 107–35.

25 Mayra Alves Soares do Amaral et al., “Effect of Music Therapy on Blood Pressure of Individuals with 

Hypertension: A Systematic Review and Meta-analysis,” International Journal of Cardiology 214 (2016): 461–64.

26 Fan Feng et al., “Can Music Improve Sleep Quality in Adults with Primary Insomnia? A Systematic Review and 

Network Meta-analysis,” International Journal of Nursing Studies 77 (2018): 189–96.

27 Stefan Koelsch et al., “Effects of Music Listening on Cortisol Levels and Propofol Consumption during Spinal 

Anesthesia,” Frontiers in Psychology 2 (2011): 58.

28 Steven Brown, Michael J. Martinez, and Lawrence M. Parsons, “Passive Music Listening Spontaneously Engages 

Limbic and Paralimbic Systems,” Neuroreport 15, no. 13 (2004): 2033–37.

29 Stefan Koelsch, “Towards a Neural Basis of Music-Evoked Emotions,” Trends in Cognitive Sciences 14, no. 3 (2010): 

131–37.

30 Stuckey and Nobel, “Connection.”

31 Kun Zhao et al., “A Systematic Review and Meta-analysis of Music Therapy for the Older Adults with 

Depression,” International Journal of Geriatric Psychiatry 31, no. 11 (2016): 1188–98.

32 Bronwyn Tarr, Jacques Launay, and Robin I. M. Dunbar, “Music and Social Bonding: ‘Self-Other’ Merging and 

Neurohormonal Mechanisms,” Frontiers in Psychology 5 (2014): 1096.

33 Saeid Raofi and Susan M. Schappert, “Medication Therapy in Ambulatory Medical Care: United States, 2003–

04,” Vital and Health Statistics. Series 13, Data from the National Health Survey 163 (2006): 1–40.

34 American Pain Society, “Pain Assessment and Treatment in the Managed Care Environment. A Position 

Statement from the American Pain Society,” The Case Manager 11, no. 5 (2000): 50.

35 Institute of Medicine (U.S.) Committee on Advancing Pain Research, Care, and Education, Relieving Pain in 

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36 Darrell J. Gaskin and Patrick Richard, “The Economic Costs of Pain in the United States,” The Journal of Pain 13, 

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37 Rolf-Detlef Treede et al., “A Classification of Chronic Pain for ICD-11,” Pain 156, no. 6 (2015): 1003–07.

38 Beth Han et al., “Prescription Opioid Use, Misuse, and Use Disorders in U.S. Adults: 2015 National Survey on 

Drug Use and Health,” Annals of Internal Medicine 167, no. 5 (2017): 293–301.
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39 Catherine E. Callinan et al., “The Initiation of Chronic Opioids: A Survey of Chronic Pain Patients,” The Journal of 

Pain 18, no. 4 (2017): 360–65.

40 Anuj Shah, Corey J. Hayes, and Bradley C. Martin, “Characteristics of Initial Prescription Episodes and Likelihood 

of Long-Term Opioid Use—United States, 2006–2015,” Morbidity and Mortality Weekly Report 66, no. 10 (2017): 265.

41 Roger Chou et al., “The Effectiveness and Risks of Long-Term Opioid Treatment of Chronic Pain,” Evidence Report/

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42 Han et al., “Prescription Opioid Use.”

43 Tick et al., “Evidence-Based Nonpharmacologic Strategies.”

44 K. L. Bronk, “New Joint Commission Advisory on Non-pharmacologic and Non-opioid Solutions for Pain 

Management,” The Joint Commission, 2018.

45 The Joint Commission, “Non-pharmacologic and non-opioid solutions for pain management,” Quick Safety 44 

(August 2018): 1–2.

46 U.S. Department of Health and Human Services, “Pain Management Best Practices Inter-Agency Task Force 

Report: Updates, Gaps, Inconsistencies, and Recommendations,” May 2019, https://www.hhs.gov/ash/advisorycommittees/pain/reports/index.html.

47 Substance Abuse and Mental Health Services Administration, Key Substance Use and Mental Health Indicators in 

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48 Substance Abuse and Mental Health Services Administration, Key Substance Use.

49 Kolodny et al., “Prescription Opioid and Heroin Crisis.”

50 Jonathan K. Phillips et al., “Trends in Opioid Use, Harms, and Treatment,” in Pain Management and the Opioid 

Epidemic: Balancing Societal and Individual Benefits and Risks of Prescription Opioid Use (Washington, DC: National 

Academies Press [U.S.], 2017), 187–266.

51 Pradip K. Muhuri, Joseph C. Gfroerer, and M. Christine Davies, “Associations of Nonmedical Pain Reliever Use 

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52 “Overdose Death Rates,” National Institute on Drug Abuse, January 2019, https://www.drugabuse.gov/relatedtopics/trends-statistics/overdose-death-rates.

53 Suzanne C. Brundage, Adam Fifield, and Lee Partridge, “The Ripple Effect: National and State Estimates of the 

U.S. Opioid Epidemic’s Impact on Children,” United Hospital Fund, 2019.

54 Erin L. Winstanley and Amanda N. Stover, “The Impact of the Opioid Epidemic on Children and Adolescents,” 

Clinical Therapeutics 41, no. 9 (2019): 1655–62.

55 U.S. Department of Health and Human Services, “Facing Addiction in America.”

56 Rebecca Kate Hodder et al., “Association between Adolescent Tobacco, Alcohol and Illicit Drug Use and 

Individual and Environmental Resilience Protective Factors,” BMJ Open 6, no. 11 (2016): e012688.
94 National Endowment for the Arts | arts.gov

57 Deborah Dowell et al., “Mandatory Provider Review and Pain Clinic Laws Reduce the Amounts of Opioids 

Prescribed and Overdose Death Rates,” Health Affairs 35, no. 10 (2016): 1876–83.

58 Substance Abuse and Mental Health Services Administration, Key Substance Use.

59 Substance Abuse and Mental Health Services Administration, Center for Behavioral Health Statistics and 

Quality, Treatment Episode Data Set (TEDS): 2017. Admissions to and Discharges from Publicly-Funded Substance Use 

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60 A. Thomas McLellan et al., “Drug Dependence, a Chronic Medical Illness: Implications for Treatment, Insurance, 

and Outcomes Evaluation,” Journal of the American Medical Association 284, no. 13 (2000): 1689–95.

61 Jin Hyung Lee, “The Effects of Music on Pain: A Meta-analysis,” Journal of Music Therapy 53, no. 4 (2016): 430–77.

62 Louisa Hohmann et al., “Effects of Music Therapy and Music-Based Interventions in the Treatment of Substance 

Use Disorders: A Systematic Review,” PloS One 12, no. 11 (2017): e0187363.

63 Karen Megranahan and Michael Thomas Lynskey, “Do Creative Arts Therapies Reduce Substance Misuse? A 

Systematic Review,” The Arts in Psychotherapy 57 (2018): 50–58.

64 Carter T. Edison and Lisa S. Panisch, “A Systematic Review of Music Therapy for Psychosocial Outcomes of 

Substance Use Clients,” International Journal of Mental Health and Addiction (2020): 1–18.

65 Quan Nha Hong et al., Mixed Methods Appraisal Tool (MMAT), version 2018, Registration of Copyright 

(#1148552), Canadian Intellectual Property Office, Industry Canada, 2018.

66 Michail Zografakis Sfakianakis et al., “Effect of Music Therapy Intervention in Acute Postoperative Pain among 

Obese Patients,” International Journal of Caring Sciences 10, no. 2 (2017): 937–45.

67 Ellahe Motahedian et al., “The Effect of Music Therapy on Postoperative Pain Intensity in Patients under Spinal 

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68 Aileen B. Stephens-Hernandez et al., “Drama-Based Education to Motivate Participation in Substance Abuse 

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69 Stephens-Hernandez et al., “Drama-Based Education.”

70 Melissa Menzer, The Arts in Early Childhood: Social and Emotional Benefits of Arts Participation: A Literature Review 

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71 Steven J. Holochwost et al., “The Arts and Socioemotional Development: Evaluating a New Mandate for Arts 

Education,” in Arts Evaluation and Assessment: Cham, Switzerland: Palgrave Macmillan, 2018), 147–80.

72 Leyre Zarobe and Hilary Bungay, “The Role of Arts Activities in Developing Resilience and Mental Wellbeing in 

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73 U.S. Health and Human Services, “Facing Addiction in America.”

74 Alicia Stinson, “A Review of Cultural Art Programs and Outcomes for At-Risk Youths,” Best Practices in Mental 

Health 5, no. 1 (2009): 10–25.

75 Denise Montgomery, “The Rise of Creative Youth Development,” Arts Education Policy Review 118, no. 1 (2017): 

1–18.

76 Erin Whinnery, Alyssa Rafa, and Kate Wolff, “Creative Youth Development: Transforming the Learning 

Environment. Education Trends,” Education Commission of the States (ECS Distribution Center, Denver, 2018).
Arts Strategies for Addressing the Opioid Crisis: Examining the Evidence 95

77 Michael J. Silverman, “Effects of a Single Lyric Analysis Intervention on Withdrawal and Craving with Inpatients 

on a Detoxification Unit: A Cluster-Randomized Effectiveness Study,” Substance Use & Misuse 51, no. 2 (2016): 

241–49.

78 Michael J. Silverman, “Songwriting to Target State Shame, Guilt, and Pride in Adults with Substance Use 

Disorder on a Detoxification Unit: A Cluster-Randomized Study,” Substance Use & Misuse 54, no. 8 (2019): 1345–54.

79 Eun-Young Hwang and Sun-Hwa Oh, “A Comparison of the Effects of Music Therapy Interventions on 

Depression, Anxiety, Anger, and Stress on Alcohol-Dependent Clients: A Pilot Study,” Music and Medicine 5, no. 3 

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80 Yadira Albornoz, “The Effects of Group Improvisational Music Therapy on Depression in Adolescents and Adults 

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81 Sung Hyun Yun and Wilfred Gallant, “Evidence-Based Clinical Practice: The Effectiveness of Music-Based 

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82 Jennifer D. Jones, “A Comparison of Songwriting and Lyric Analysis Techniques to Evoke Emotional Change in a 

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83 Susan C. Gardstrom and Wiebke S. Diestelkamp, “Women with Addictions Report Reduced Anxiety after Group 

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84 Susan C. Gardstrom et al., “The Impact of Group Music Therapy on Negative Affect of People with Co-occurring 

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85 Thomas Hans Fritz et al., “Benefits of Listening to a Recording of Euphoric Joint Music Making in Polydrug 

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86 Mattye Laurer and Renée van der Vennet, “Effect of Art Production on Negative Mood and Anxiety for Adults in 

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87 Michael J. Silverman, “Effects of Lyric Analysis Interventions on Treatment Motivation in Patients on a 

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88 Vasileios Stamou et al., “Music-Assisted Systematic Desensitization for the Reduction of Craving in Response to 

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89 Daniel L. Dickerson et al., “Drum-Assisted Recovery Therapy for Native Americans (DARTNA): Results from a 

Pretest and Focus Groups,” American Indian and Alaska Native Mental Health Research (Online) 21, no. 1 (2014): 35–54.

90 Paula J. Gardner and Jennifer M. Poole, “One Story at a Time: Narrative Therapy, Older Adults, and Addictions,” 

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91 Genevieve A. Dingle, Libby Gleadhill, and Felicity A. Baker, “Can Music Therapy Engage Patients in Group 

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92 Ian J. Koebner et al., “The Art of Analgesia: A Pilot Study of Art Museum Tours to Decrease Pain and Social 

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93 Debbie Bates et al., “Music Therapy for Symptom Management after Autologous Stem Cell Transplantation: 

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94 Bates et al., “Music Therapy for Symptom Management.”

95 Lisa M. Gallagher, Ruth Lagman, and Lisa Rybicki, “Outcomes of Music Therapy Interventions on Symptom 

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96 Koebner et al., “Art of Analgesia.”

97 Leon Rodgers and Charné Furcron, “The Dynamic Interface between Neuromaturation, Risky Behavior, Creative 

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98 National Organization for Arts in Health, “Code of Ethics for Arts in Health Professionals and Standards for Arts 

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99 Sheri L. Robb, Janet S. Carpenter, and Debra S. Burns, “Reporting Guidelines for Music-Based Interventions,” 

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100 Jarrod E. Dalton, Shari D. Bolen, and Edward J. Mascha, “Publication Bias: The Elephant in the Review,” 

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101 Ana Mlinarić, Martina Horvat, and Vesna Šupak Smolcˇić, “Dealing with the Positive Publication Bias: Why You 

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102 Hilary Moss, “Arts and Health: A New Paradigm,” Voices: A World Forum for Music Therapy 16, no. 3 (2016).

103 Stéphane Guétin et al., “The Effects of Music Intervention in the Management of Chronic Pain: A Single-Blind, 

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104 U. A. Chris Okafor et al., “Effect of Aerobic Dance on Pain, Functional Disability and Quality of Life on Patients 

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105 Josie Billington et al., “A Literature-Based Intervention for People with Chronic Pain,” Arts & Health 8, no. 1 

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106 James Dahlhamer et al., “Prevalence of Chronic Pain and High-Impact Chronic Pain among Adults—United 

States, 2016,” Morbidity and Mortality Weekly Report 67, no. 36 (2018): 1001–06.

107 Güler Balcı Alparslan et al., “Effects of Music on Pain in Patients with Fibromyalgia,” Clinical Rheumatology 35, 

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108 Joke Bradt et al., “The Impact of Music Therapy versus Music Medicine on Psychological Outcomes and Pain in 

Cancer Patients: A Mixed Methods Study,” Supportive Care in Cancer 23, no. 5 (2015): 1261–71.

109 Laura D. McRee, Stacie Noble, and Alice Pasvogel, “Using Massage and Music Therapy to Improve Postoperative 

Outcomes,” AORN Journal 78, no. 3 (2003): 433–47.

110 Brown et al., “Passive Music Listening.”

111 Koelsch, “Music-Evoked Emotions.”

112 U.S. Department of Health and Human Services, “Facing Addiction in America.”

113 Mohammad Shahzad et al., “A Population-Based Approach to Integrated Healthcare Delivery: A Scoping Review 

of Clinical Care and Public Health Collaboration,” BMC Public Health 19, no. 1 (2019): 708.
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114 Bente Irene Løkken et al., “Are Playing Instruments, Singing or Participating in Theatre Good for Population 

Health? Associations with Self-Rated Health and All-Cause Mortality in the HUNT3 Study (2006–2008), Norway,” in 

Music and Public Health. Cham, Switzerland Springer, 2018), 33–54.

115 Christina Davies, Matthew Knuiman, and Michael Rosenberg, “The Art of Being Mentally Healthy: A Study 

to Quantify the Relationship between Recreational Arts Engagement and Mental Well-Being in the General 

Population,” BMC Public Health 16, no. 15 (2015).

116 Maury Nation et al., “What Works in Prevention: Principles of Effective Prevention Programs,” American 

Psychologist 58, no. 6–7 (2003): 449.

117 Bobby P. Smyth et al., “Lapse and Relapse following Inpatient Treatment of Opiate Dependence,” Irish Medical 

Journal 103, no. 6 (2010): 176–79.

118 McLellan et al., “Drug Dependence.”

119 Maithili Kadam et al., “A Comparative Study of Factors Associated with Relapse in Alcohol Dependence and 

Opioid Dependence,” Indian Journal of Psychological Medicine 39, no. 5 (2017): 627.

120 Sally Wasmuth and Kevin Pritchard, “Theater-Based Community Engagement Project for Veterans Recovering 

from Substance Use Disorders,” American Journal of Occupational Therapy 70, no. 4 (2016): 7004250020p1–

7004250020p11.

121 Ana Filipa Correia and Sofia Barbosa, “Cinema, Aesthetics and Narrative: Cinema as Therapy in Substance Use 

Disorders,” The Arts in Psychotherapy 60 (2018): 63–71. 

122 SUPPORT for Patients and Communities Act, H.R.6, 115th Cong. (2017–18), accessed October 10, 2019, 

https://www.congress.gov/bill/115th-congress/house-bill/6?q=%7B%22search%22%3A%5B%22%5C%22SUPP

ORT+for+Patients+and+Communities+Act%5C%22%22%5D%7D&s=3&r=2.

123 Callinan et al., “Initiation of Chronic Opioids.”

124 U.S. Department of Health and Human Services, “Pain Management Best Practices.”

125 U.S. Department of Health and Human Services, “Facing Addiction in America.”

126 Treede et al., “Classification of Chronic Pain.”

127 Treede et al., “Classification of Chronic Pain.”

128 National Coalition of Creative Arts Therapies Associations Inc. (website), accessed October 10, 2019, https://

www.nccata.org.

129 Quan Nha Hong et al., “Mixed Methods Appraisal Tool (MMAT), version 2018.”

130 Ibid.

131 Andrea Skelly et al., Noninvasive Nonpharmacological Treatment for Chronic Pain: A Systematic Review, Report No. 

18-EHC013-EF (Rockville, MD: Agency for Healthcare Research and Quality, 2018).

132 U.S. Department of Health and Human Services, “Facing Addiction in America.”

133 American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders Fifth Edition (DSM-5®) 

(Washington, DC: American Psychiatric Publishing, 2013).
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134 “Risk and Protective Factors,” Substance Abuse and Mental Health Services Administration, accessed October 

10, 2019, https://www.samhsa.gov/sites/default/files/20190718-samhsa-risk-protective-factors.pdf.

135 Quan Nha Hong et al., “Mixed Methods Appraisal Tool (MMAT), version 2018.”

136 Ibid.

137 Ibid.

138 Ibid.

139 “Risk and Protective Factors,” Substance Abuse and Mental Health Services Administration.

140 Substance Abuse and Mental Health Services Administration, Key Substance Use.

141 American Psychiatric Association, DSM-5®.
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