Massage to Ease Medication Dependence

Swedish Massage Therapy - PRO Therapeutic Massage in Santa Barbara, Goleta
Swedish Massage Therapy – PRO Therapeutic Massage in Santa Barbara, Goleta

Detox & Traditional Massage

Massage offers a combination of Swedish/Deep Tissue massages. Physical, psychological and emotional components must be considered in order to encourage a successful recovery, which makes massage therapy a relaxing and calming treatment option.

Addiction changes brain chemistry. Normally, your brain produces a chemical called dopamine. Dopamine is a key to pleasure. It is used by your brain to encourage you to continue to do something that is required for survival. Eating and sex are two activities that naturally trigger large dopamine releases in our brains. When dopamine is released we feel good so we want to continue to do that thing so we can continue to feel good.

Addictive behaviors trigger a release of dopamine. This release is much higher than what the body can do naturally. Because of the high amount of dopamine produced by the drug you are driven more and more to repeat that behavior. The overt time you become dependent on the drug to release dopamine. When you’re going through the withdrawal process your dopamine levels are lower than the average person.

Massage helps increase the levels of dopamine in the brain. When given consistently over an extended period of time it causes dopamine levels to increase steadily. It can be used to help normalize the production of dopamine in a person going through the withdrawal process.

Massage also decreases stress. Recovering from an addiction puts the body through a tremendous amount of stress. Massage decreases the production of the stress hormone cortisol in the body. It also triggers the parasympathetic nervous system which helps slow breathing and heart rate relaxing the body.

Detoxification is an important part of addiction recovery. The remaining drugs in your body must be pushed out to give you a chance of full recovery. Massage also helps with detoxification by increasing the circulation of blood and lymph. This helps the body flush out the toxic chemicals leftover from drug abuse more quickly.

Massage on its own cannot help someone completely recover from addiction, but combined with the right other therapies, it can make the recovery process easier

Massage Therapy offers an abundance of additional benefits including:

  • Decrease physical muscle pain
  • Ease of medication dependence
  • Increase joint flexibility /circulation
  • Promote tissue regeneration
  • Reduce muscle spasm/cramping
  • Enhance sleep quality
  • Improve energy
American Massage Therapy Association

Massage Therapy as an Alternative to Opioids

Prescription opioids carry a serious risk of addiction, abuse, and overdose, in addition to a number of side effects, even when taken as directed. According to the Centers for Disease Control, deaths from prescription opioids—drugs like oxycodone, hydrocodone, and methadone—have more than quadrupled since 1999.  

For that reason, a number of health organizations and governmental agencies are seriously looking at alternative ways to manage pain.

The American Massage Therapy Association (AMTA) continues to be actively engaged with several organizations, as well as federal and state governmental agencies regarding massage therapy for pain and specifically as an alternative to opioids.

In the News: Massage as an Alternative to Opioids

  • July 2019 – Florida passed a new law that requires the Department of Health to develop and publish an online educational pamphlet on the use of non-opioid alternatives for pain, including massage therapy. The publication to include information about the advantages of each non-opioid approach, with references on its efficacy. This legislature will make a difference in how the residents of Florida view their options for pain care and management, with a clear endorsement of massage therapy. Learn more about the new Florida law »
  • February 2019 – The U.S. Senate Health, Education, Labor & Pension Committee (H.E.L.P) held a hearing on the opioids crisis in the country, which was focused on approaches to pain other than opioids. AMTA’s representative attended the session where testimony was given on the importance of nonpharmacological approaches to pain (including massage therapy) and the need for more insurance carriers to cover these approaches. Those referring to the value of massage therapy and the challenges of lack of insurance coverage included Halena Gazelka, M.D., Assistant Professor of Anesthesiology and Perioperative Medicine, Director, Mayo Clinic Inpatient Pain Service. She stated, “…we want to offer services like massage therapy, but have issues with reimbursement.”
  • January 2019 – The Centers for Medicare and Medicaid Services (CMS) wrote to all Medicare Advantage programs encouraging them to cover massage therapy in 2020, going beyond their 2019 recommendation to consider massage coverage. Their letter now says the following about “Non-Opioid Pain Management Supplemental Benefits” “CMS encourages MA (Medicare Advantage) organizations to consider Part C benefit designs for supplemental benefits that address medically-approved non-opioid pain management and complementary and integrative treatments. For example, “peer support services” delivered by qualified individuals may be effective in facilitating recovery and assist in navigating health care resources. For purposes of completing the PBP, peer support services and/or psychosocial services/cognitive behavioral therapy can be included in counseling services (PBP 14c). In addition, non-Medicare covered chiropractic services (PBP 7b), acupuncture (PBP 13a), and therapeutic massage (PBP B14c) furnished by a state-licensed massage therapist may also be incorporated into plan designs. “Massage” should not be singled out as a particular aspect of other coverage (e.g., chiropractic care or occupational therapy) and must be ordered by a physician or medical professional in order to be considered primarily health-related and not primarily for the comfort or relaxation of the enrollee. The non-opioid pain management item or service must treat or ameliorate the impact of an injury or illness (e.g., pain, stiffness, loss of range of motion).”
  • January 2019 – The U.S. Department of Health and Human Services (HHS), through an Inter-Agency Task Force, published a draft report on pain management best practices. This draft calls for individualized, patient-centered pain management, and it includes recommendations related to massage therapy.
  • September 2018 – CMS has announced that many Medicare Advantage plans will cover massage therapy for pain management, provided by a state-licensed massage therapist, beginning in 2019. “As a result of the new flexibilities on supplemental benefits available for the first time in 2019, about 270 plans are providing nearly 1.5 million enrollees with access to the following new types of benefits: expanded health-related supplemental benefits, such as adult daycare services, in-home services, caregiver support services, home-based palliative care and therapeutic massage.”
  • August 2018 – AMTA began an outreach effort with approximately 700 Medicare Advantage insurance companies encouraging them to follow the Center for Medicare Services recommendations by covering medically-approved massage therapy provided by state-licensed massage therapists. While coverage of massage therapy is not automatic, AMTA is asking Medicare Advantage plans to consider it for 2019 and 2020.
  • August 2018 – AMTA published Massage Therapy in Integrative Care & Pain Managementa detailed overview of research on the efficacy of massage therapy and results of economic modeling indicating that using massage therapy instead of opioids for specific types of pain, could save the U.S. between $23 and $25 billion each year.
  • Fall 2017 – AMTA met with a representative and provided feedback to the FDA regarding the important role massage therapy can play. The FDA released guidelines calling on health care providers to be informed on the range of therapeutic options for managing pain, including non-pharmacologic approaches and therapies. While the FDA was not specific about these approaches, the National Institutes of Health (NIH) has for several years now, including massage therapy among its list of complementary therapies.
  • Fall 2017 – The U.S. Food & Drug Administration (FDA) sought public comment on the “FDA Education Blueprint for Health Care Providers Involved in the Management or Support of Patients with Pain”.  Learn more »
  • Fall 2017 – Consumer Reports discussed massage therapy as an approach to low back pain.
  • September 2017 – 37 US Attorney Generals called for Inclusion of Massage in Insurance Coverage. See the coverage in ABC News, and read the letter.
  • NBC medical correspondent Dr. John Torres reported on the Today Show that the CDC recommends massage therapy, NSAIDs, and acupuncture as an alternative to opioids. Watch the Today Show Segment »

Clinical Recommendations – Massage Therapy for Pain

Relaxing Swedish Massage
relaxing Swedish with hand massage
  • January 2019 – The Joint Commission published its updated standards for non-pharmacologic strategies for pain, which include the use of massage therapy.
    https://www.jointcommission.org/standards_information/jcfaqdetails.aspx?StandardsFaqId=1813&ProgramId=46
    https://www.jointcommission.org/new_joint_commission_advisory_on_non-pharmacologic_and_non-opioid_solutions_for_pain_management/
    https://www.jointcommission.org/new_revised_pain_assessmentmanagement_standards_for_behavioral_health_care_home_care_nursing_care_to_be_introduced/
  • September 2018 – The final draft of the “U.S. Food and Drug Administration’s (FDA’s) Blueprint for Health Care Providers Involved in the Management or Support of Patients with Pain” includes a recommendation of complementary therapies as defined by NIH/NCCIH. The Opioid Analgesic REMS (Risk Evaluation and Mitigation Strategy) program requires that health care providers receive training on pain management, and should be knowledgeable about the range of non-pharmacologic treatment options available. 
  • April 2018 – The Center for Medicare Services published new guidelines for Medicare Advantage programs coverage in 2019. “medically-approved Non-Opioid Pain Management (PBP B13d, e, or f): Medically-approved non-opioid pain treatment alternatives, including therapeutic massage furnished by a state-licensed massage therapist. Massage should not be singled out as a particular aspect of other coverage (e.g., chiropractic care or occupational therapy) and must be ordered by a physician or medical professional in order to be considered primarily health-related and not primarily for the comfort or relaxation of the enrollee. The non-opioid pain management item or service must treat or ameliorate the impact of an injury or illness (e.g., pain, stiffness, loss of range of motion).” Medicare Managed Care Manual Chapter 4 – Benefits and Beneficiary Protections
  • The American College of Physicians issued guidelines recommending massage therapy for low-back pain in 2017.
  • The Federation of State Medical Boards issued recommendations in April 2017 on approaches to pain, including massage therapy among non-pharmacologic therapies.
  • Since November 2014, The Joint Commission hospital standards for non-pharmacologic strategies for pain included the use of massage therapy. [Joint Commission Perspectives, Volume 34, Number 11, November 2014, pp. 11-11(1). Clarification to Standard PC.01.02.07]

Integrative Collaborations

AMTA continues to work with a variety of national integrative care groups to promote the inclusion of massage therapy into approaches to pain other than opioids.

  • January 2019 – AMTA begins active discussions with the Academic Consortium for Integrative Medicine and Health on collaborative approaches to massage therapy research and national health care policy. The consortium is a nonprofit organization of more than 70 highly-esteemed academic medical centers and affiliate institutions whose mission is to advance the principles and practices of integrative healthcare within academic institutions. The group invited AMTA to make a presentation to its members in March.
  • The Spring 2018 issue of The Pain Practitioner included an article by AMTA Past President Dolly Wallaceon massage therapy as an alternative to opioids for pain. 
  • The Spring 2017 issue of The Pain Practitioner included an article by AMTA President Dolly Wallace on the benefits of massage therapy for people with arthritis.

Helping Government Address Opioid Use

  • February 2019, the U.S. Department of Health and Human Services (HHS), through an Inter-Agency Task Force, published a draft report on pain management best practices. This draft calls for individualized, patient-centered pain management, and it includes recommendations related to massage therapy. AMTA provided comments to improve the pain management plan and continues to be actively engaged with HHS and the Task Force to work toward massage therapy’s full inclusion as part of the recommendations. This has included direct meetings with the chair of the Task Force and other stakeholder groups. Read the full report https://www.hhs.gov/ash/advisory-committees/pain/reports/2018-12-draft-report-on-updates-gaps-inconsistencies-recommendations/index.html
  • August 2018, AMTA began distributing its new resource, Massage Therapy in Integrative Care & Pain Management, to federal and state governmental agencies, as well as, insurers and health care organizations. This document reinforces strong research on the efficacy of massage therapy and features results of economic modeling indicating that using massage therapy instead of opioids for specific types of pain could save the U.S. between $23 and $25 billion each year.
  • On March 14, 2018, AMTA representatives met with senior staff at the National Center for Complementary and Integrative Health, part of the National Institutes of Health (NIH). The meeting focused on the necessity of increasing the amount of massage therapy research, as massage therapy has become more accepted as an important approach to managing pain.
  • Late 2017 and early 2018, AMTA provided detailed information on the efficacy of massage therapy for pain to the U.S. House of Representatives Ways & Means Committee and its Energy & Commerce Committee, as they prepared for hearings related to the opioid crisis.
  • AMTA worked directly with the West Virginia Attorney General on a program to reduce the use of opioids for pain. The state has been positive about the incorporation of massage therapy in a list of approaches to pain that can help stop the rampant use of opioids there – the highest in the country. The state public education program includes a recommendation of massage therapy as a first-line approach vs. opioids. As a result, AMTA has been actively discussing a similar approach with legislators in an increasing number of states.
  • AMTA also connected the state officials in West Virginia with researchers in Kentucky working on this same subject. We have an ongoing relationship with researchers at the University of Kentucky for educational roundtables in West Virginia and Kentucky. They recently published some of their results, showing the value and efficacy of massage as a substitute for opioids.
  • December 2017, AMTA submitted recommendations to the Agency for Healthcare Research and Quality (an agency of the U.S. Department of Health & Human Services) for the inclusion of research on massage therapy for chronic pain, to be included in their analysis and recommendations for non-pharmacologic approaches.
  • October 2017, AMTA was an exhibitor at the Appalachian Opioid Conference and met with state officials from multiple states about how to integrate massage therapy into non-pharmacologic approaches to pain as a way to counter the national opioid epidemic.

Research & Resources Supporting Massage for Pain Management

Massage vs. Opioids fact sheet »

Learn more about AMTA’s Massage Therapy in Integrative Care & Pain Management Resource 

The Massage Therapy Foundation and Samueli Institute research meta-analysis funded by AMTA will help continue conversations on this important topic.


Additional Resources

Current Research on the Health Benefits of Massage Therapy

Communicating + Collaborating with Health Care Professionals

Low Back Pain & Massage Therapy | 2.5 CE Credits

Massage & Addiction

Athletic Sports Performance Massage Therapy, Santa Barbara, Goleta
Athletic Sports Performance Massage Therapy, Santa Barbara, Goleta

When Brendan C., a Chicago-based marathon runner, and coach and recovering alcoholic with 20 years of sobriety under his belt, went for a recent massage with his regular therapist, the muscles in his calves and lower back were intractable. His therapist asked him what was going on. Brendan said he had no idea.

The therapist continued working on him. As she did, Brendan began to feel profoundly sad. He realized he was finally feeling the stress fall-out of the recent break-up of a long-time relationship. Only then did his muscles begin to release. “That’s the thing with addicts,” he says, wryly. “We don’t always know what’s going on with us.”

This emotional disassociation can often be a double whammy for those struggling with addictions. “We live in a culture that doesn’t do a good job teaching anyone how to relax, both physically and mentally,” says Jennifer Broadwell, DOM, ADS, an acupuncturist and director of the Wellness Spot, an integrative health center affiliated with the Florida House Experience, a rehab facility based in Deerfield Beach, Florida.

However, this could be changing. More and more, centers such as the Wellness Spot offer a host of non-talk therapies, including massage, as part of their recovery programs. In fact, massage is one of the most popular offerings at the Wellness Spot, with the six therapists doing approximately 200 massages a week.

The center also offers acupuncture, chiropractic services, yoga, meditation, and nutritional counseling. Through all of these modalities, but especially massage, “Clients can now feel what it’s like to be present in their own bodies,” says Broadwell.


The Long Road

Recovery is a process, and a difficult one. “Often, the client cannot even articulate what is going on,” Broadwell says. “Because massage is not talk therapy, it can meet them wherever they are, even if they don’t have the skills to tell us.”

Maureen Schwehr, NMD, a naturopathic physician and craniosacral instructor who works at the integrative clinic at Sierra Tucson, an in-patient rehab facility near Tucson, Arizona, says bodywork offerings are invaluable to the rehab clients, almost all of whom choose to participate in them. The massage offerings at Sierra Tucson include Swedish massage, myofascial release, zero balancings, shiatsu, SomatoEmotional Release, and Chi Nei Tsang, a type of Chinese abdomen massage.

Schwehr says that most conventional therapy for recovery focuses on the mind. Once you start considering a mind/body/spirit model, she explains, you have more treatment options. She thinks of the connection this way: “The spirit is who we really are. Our mind is our thinking brain, and our body houses this. If you’re an addict, you often have to ignore your body, because you are, in essence, hurting your ‘house.’” Addicts often continue their destructive behavior by not checking in with their ‘home,’ or their body, she says.

About Addiction

Of course, destructive addictive behavior can have ramifications far beyond the individual addict. According to the National Institute on Drug Abuse (NIDA), addictions impact nearly all American families in some way. Alcohol, nicotine and illegal substances alone cost more than half a trillion dollars a year, in everything from health care costs to crime to accidents to special services in education.

The jury is still out on what causes addiction—most experts say it’s a combination of physiological susceptibility and environment. However, nearly everyone agrees that recovery is not about simple willpower. As one well-known Alcoholics, Anonymous aphorism says, “We’re sick people trying to get better, not bad people trying to be good.”

Gabor Mate, M.D., a physician who worked with addicts in the drug-infested Downtown Eastside of Vancouver for years and author of In the Realm of the Hungry Ghost: Close encounters with addiction, says that addiction seems designed to help users escape the pain. “All addictions serve as distractions at the very least,” he says.

Nearly any behavior can be addictive—even seemingly benign activities such as shopping, eating, and sex. Mate says it really doesn’t matter what the “drug” of choice is—all addictions involve the same brain circuits and brain chemicals. The NIDA says that when addicts get a hit of their drug of choice, dopamine—the feel-good neurotransmitter—floods their brain’s reward system.

The Benefits of Massage & Addiction

This may be why massage, which has been proven to increase dopamine and serotonin and decrease cortisol, can help those in recovery. Schwehr says this piece is crucial, especially in the early stages of withdrawal when dopamine often drops significantly. “This can be a very uncomfortable time,” she says.

Other physiological and emotional issues in recovery include pain, agitation, anxiety and sleep problems. Massage—nearly any kind of massage—also helps with all of these, says Tiffany Field, Ph.D., director of the University of Miami’s School of Medicine’s Touch Research Institute, which studies massage. “The body releases fewer stress hormones when being massaged,” Field says. Stress hormones, including cortisol, weaken the immune system and can lead to increased pain.“ This becomes, a vicious cycle,” Field says, “one that massage can help break.”

Also, in a study published in 2002, fibromyalgia patients, after receiving massage twice weekly for five weeks, slept and felt better. Levels of neurotransmitter substance P—which your body emits when you are sleep deprived—decreased. “We found a direct relationship,” says Field.

Related: The Power of Touch for Fibromyalgia

Massage also helps with overall relaxation by stimulating pressure receptors, which enhance vagal activity. Since the vagus nerve is one of the 12 cranial nerves in the brain, this decreases heart rate, lowers blood pressure, and decreases stress hormones, according to Field. “You will sleep better, be less anxious,” says Field. “It’s a whole chemical reaction that is happening.”

Even those who are going through withdrawal from alcohol, cocaine or opioids relaxed more deeply with a simple chair massage than with 20-minute “relaxation sessions,” where participants sat in a quiet room and focused on their breathing. And those who received the massage sustained the relaxation benefits for 24 hours.

On a more superficial level, clients often just feel better after a massage, says Broadwell. “We’re able to show them, ‘This is what relaxation feels like,” she says. “Someone puts healing hands on you, and suddenly you become aware,” Mate says. “Often people say, ‘I never knew I was that sad/happy.’” To this end, massage therapists may have an advantage over medical doctors like him when working with this clientele, says Mate.

“Massage therapists get the stress/disease connection more than doctors do,” he says. “They actually can feel when a client is holding some tension. Physicians don’t put their hands on people like that.”

Related: Research – Massage Can Relieve Stress

In Mate’s experience, most of the addicts he worked with—if not all—suffered early life trauma. In fact, he sees childhood trauma and emotional loss as the template for addictions. Many had boundaries violated. Therefore, tread carefully. Ground yourself first. “Make sure what you’re doing is to help them—not to be a hero, or to save anyone,” he says. If a client relapses, he says, and you get angry with them, then you are in a sense violating their boundaries. “Whatever happens to them, don’t take it personally,” Mate adds.

Related: In Safe Hands: Massage & PTSD

Diane Ansel, a Chicago-based massage therapist, says consider yourself a guide more than anything. “You work on them, and let it go. It’s up to them to turn it around,” she explains.

What you can offer, she says, is simple self-care techniques for between sessions. Ansel says she often takes inspiration in a long-told story of Gandhi. “I love the story of a mother who came to Gandhi and asked him to tell her child not to eat sugar,” she says. “Gandhi said to come back next week. When they returned, Gandhi simply told the child, ‘Stop eating sugar.’ When the mother asked, why did they have to go and return for that? He replied, ‘I hadn’t given up sugar yet.’”

Mate says we can’t all wait until we’re perfect in order to help others. “To the extent that you haven’t dealt with your own stuff—or glimpsed your own possibilities—for you can only take people as far as you can go yourself. But no one ever finishes, so you don’t have to wait, just be aware. It takes a lot of self-awareness,” he says.

He also says that, in essence, all addictions are about self-soothing. Therefore, giving them a pathway with which they can connect to their bodies can be enormously empowering. Broadwell sees this with the clients at her wellness center all the time.

The clients start to realize, she says, that the “medicine” is inside of them. “This is a great paradigm shift,” she explains. First, she sees the effects of massage on the faces of the clients. “And then we hear it everyday inpatient feedback: That the chronic pain is starting to improve, that they can now sleep with less or no medication,” she adds.

Schwehr says that one of her clients told her that the massage changed her experience at the rehab facility by “100 percent.” Another client told her that the bodywork she had done allowed her to feel connected to her body in a way she had never felt before.

Massage can even help with some basic rewiring of our brains, knowing what we know now about its neuroplasticity. Often, says Mate, early touch experiences of those who struggle with addiction have been “the opposite of healing,” which is partly why he advocates compassionate treatment for addicts rather than tough love. “[With massage therapy,] when they are being touched, it is not to give someone else pleasure, but to put themselves in touch with themselves,” he says. “If there’s some brain circuit that says to be touched is to be hurt,” Mate adds, “imagine being touched not to be hurt, but to be helped.”

Brendan C. experiences this rewiring, one day at a time. Twenty years sober, he says he’s still learning every day how to get in touch with his body and his feelings. Brendan says that many people with addictive personalities do not feel comfortable touching or being touched, himself included. “Part of the reason I drank,” he says, “was to avoid having intimate contact with those around me—my parents, children, wife.”

However, being willing to open up and to trust has made a world of difference. “Massage builds trust. Perhaps for the first time, the body can be completely relaxed, receptive, without the fear that the other person is going to hurt you,” he says.

This is what Schwehr sees all the time at the clinic, she says. “When someone has an opportunity to be touched, to have therapeutic work on their body, it can bring the [recovery] work home to a much deeper level,” she believes. “It can help connect the body to the emotions. I once read that emotion are our body’s way of telling us how it feels about what’s going on. When you bring someone back to their body, it’s like bringing them home.”


Tips for Working With Massage Clients in Recovery

According to Maureen Schwehr, NMD, a naturopathic physician and craniosacral instructor who works at the integrative clinic at Sierra Tucson, an in-patient rehab facility near Tucson, Arizona, these tips for massage therapists working with those in recovery:

1. Be neutral and don’t have an agenda about what you want out of the session. let the client’s needs guide you.

2. Be really clear about your professional boundaries. “People with addictions can be good at crossing boundaries, so therapists have to be really clear on theirs,” she says. Don’t bring your own personal stuff into the sessions. Work at a very professional level.

3. Be clear about what population you are willing to work with. Don’t take on clients beyond your capabilities. At different stages of recovery, clients may need different types of work. It’s not one-size-fits-all. “Be OK with referring out if it seems that what’s going on is more complex than you are willing to handle,” she encourages.

Further Reading:

https://www.altamirarecovery.com/blog/helping-hands-benefits-massage-therapy-addiction-treatment/


https://stjosephinstitute.com/7-surprising-benefits-of-massage-therapy-during-recovery/


https://www.beachway.com/massage-therapy-for-addiction-recovery/


https://www.integrativehealthcare.org/mt/massage-for-addiction-recovery/


https://www.uspharmacist.com/article/massage-therapy-implications-for-pharmaceutical-care


https://fherehab.com/services/massage-therapy/

*Disclaimer: This information is not intended to be a substitute for professional medical advice. You should not use this information to diagnose or treat a health problem or disease without consulting with a qualified healthcare provider.
Please consult your healthcare provider with any questions or concerns you may have regarding your condition.
The information provided is for educational purposes only and is not intended as diagnosis, treatment, or prescription of any kind. The decision to use, or not to use, any information is the sole responsibility of the reader. These statements are not expressions of legal opinion relative to the scope of practice, medical diagnosis or medical advice, nor do they represent an endorsement of any product, company or specific massage therapy technique, modality or approach. All trademarks, registered trademarks, brand names, registered brand names, logos, and company logos referenced in this post are the property of their owners.

Therapeutic Massage, Sports Massage Therapy in Santa Barbara, Goleta
Therapeutic Swedish Massage, Sports Massage Therapy in Santa Barbara, Goleta
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Nicola of Riktr Pro Massage is a practicing licensed insured professional LMT (Licensed Massage Therapist) and fine artist based in Santa Barbara, CA. Nicola has a wide range of female and male clients, including athletes, professionals, housewives, artists, landscapers, out of town visitors, people who are retired and students.

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