A pilot study of aerobic exercise as an adjunctive treatment for drug dependence
Introduction
Drug dependence is a major public health problem (McCrady and Epstein, 1999, Rotgers et al., 1996) and the associated costs of drug use disorders to society are considerable (Andlin-Sobocki, 2004, Langenbucker et al., 1993, ONDCP, 2004). Results from the U.S. National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) point toward high rates of substance use disorders (SUD) with 9.5% of the population meeting DSM-IV criteria for any SUD and 4.07% meeting criteria for any substance dependence within the last 12 months (Grant et al., 2004). Epidemiological data from 27 community studies in European countries reveal a 12-month prevalence rate for any substance dependence of 3.4% of the adult population (Wittchen & Jacobi, 2005). Spontaneous remission rates from drug diagnoses are very low (Finney, Moos, & Timko, 1999). Relapse represents a major problem in substance use disorders, with relapse rates in the first year following treatment ranging from 60 to 90% (Brownell et al., 1986, Hunt et al., 1971, Xie et al., 2005). Therefore, it is crucial that accessible, affordable and efficacious primary and adjunctive drug dependence treatments be developed to address this chronic, relapsing condition.
The role of increasing lifestyle balance has been incorporated in existing relapse prevention models (Marlatt and Witkiewitz, 2005, Witkiewitz and Marlatt, 2004). Indeed, in his chapter on “Lifestyle Modification,” Marlatt cites exercise as “a highly recommended lifestyle change activity” (Marlatt, 1985, p. 309) and discusses the advantages of physical activity as a relapse prevention strategy. Other writers have agreed that lifestyle-enhancing factors such as exercise and fitness may play an important role in the prevention and treatment of addictive disorders (Brown et al., 2009, Tkachuk and Martin, 1999). Larimer and colleagues (Larimer, Palmer, & Marlatt, 1999) describe the importance of helping the client develop “positive addictions” such as increased physical activity and meditation. Although lifestyle modification was one of the main components in Marlatt’s relapse prevention model [see Marlatt and Donovan (2005) for more details], the treatment outcome literature suggests that this component has received the least emphasis in relapse prevention programs for drug dependence. Despite this lack of attention in the empirical literature, methods that attempt to foster healthy lifestyle changes may contribute to long-term maintenance of recovery, and interventions targeting physical activity in particular, may be especially valuable as an adjunct to substance abuse treatment.
Exercise may benefit drug dependent patients attempting recovery from substance problems through a number of different mechanisms of action. First, engaging in exercise may offer drug dependent patients the ability to experience positive mood states without the use of drugs. For example, due to the potential for reductions in dopamine production and dopamine receptors availability, drug dependent patients may have an impaired capacity to experience pleasure during early recovery (Adinoff, 2004, Bressan and Crippa, 2005). On the other hand, exercise has been shown to result in acute improvements in positive-activated affect (e.g., Reed & Ones, 2006) and alleviate mood disturbance and withdrawal symptoms in women attempting to quit smoking (e.g., Bock, Marcus, King, Borrelli, & Roberts, 1999). These positive reinforcing properties may be mediated in part by exercise effects on the endogenous opioid system and potentiation of dopaminergic systems linked importantly to the experience of enhanced mood and experienced pleasure (cf., (Meeusen, 2005), although the application of neuroscience techniques to exercise psychology is complex and will require strong research designs (Dishman & O’Connor, 2009). Second, studies in recent years have found an association between depressive symptomatology and poor treatment outcome among patients with substance use disorders (Brown et al., 1998, Nunes and Levin, 2004, Ouimette et al., 1999, Poling et al., 2007). Engaging in exercise has been consistently associated with reductions in depressive symptoms (Craft and Landers, 1998, Dunn et al., 2001, Lawlor and Hopker, 2001, Mead et al., 2009) and thus exercise may reduce risk for relapse by reducing depressive symptoms. Third, exercise has been found to alleviate sleep disturbances (Youngstedt, 2005) and improve cognitive functioning (Kramer & Erickson, 2007) – both of which have been identified as disrupted in early drug recovery and predictive of relapse (Drummond et al., 1998, Ersche and Sahakian, 2007, Gruber et al., 2007, Jovanovski et al., 2005, Liu et al., 2000, Rogers and Robbins, 2001, Scott et al., 2007). Lastly, increases in self-efficacy (McAuley, Courneya, & Lettunich, 1991) and decreases in stress-reactivity (Hobson and Rejeski, 1993, Keller, 1980) associated with exercise engagement may also contribute to lower the risk of relapse among drug dependent patients. Among problem drinkers, exercise led to psychological improvement in physical self-worth and physical self-perceptions of condition and strength (Donaghy & Mutrie, 1998). Exercise has been proposed as an effective relapse prevention intervention specifically due to the potential number of positive physiological and psychological benefits. Improved mood, regulated reward systems, reduced depressive symptoms, improved sleep and cognitive function all may serve to reduce risk for relapse and efforts to illuminate mechanisms of effectiveness will be an important focus of future work in this area.
Thus far, few studies have examined the efficacy of aerobic exercise as adjunct to substance abuse treatment. Among addictive disorders, nicotine dependence has received the most attention with respect to the role of physical activity. Recent studies have demonstrated the acute effects of exercise on decreased craving and nicotine withdrawal (see Taylor, Ussher, & Faulkner, 2007) and as a means of facilitating smoking cessation (Marcus et al., 1999, Marcus et al., 2005, Prapavessis et al., 2007).
The role of exercise as an adjunct to alcohol treatment has been explored by Sinyor and colleagues (Sinyor, Brown, Rostant, & Seraganian, 1982) who reported on 58 participants receiving inpatient alcohol rehabilitation treatment. Participants engaged in six weeks of “tailored” exercise, consisting of progressively more rigorous physical exercise including stretching, calisthenics and walking/running. Results revealed that these participants demonstrated better abstinence outcomes post-treatment than did non-exercising participants from two other small comparison groups. In addition, in a previous study, we developed and pilot tested a 12-week moderate-intensity aerobic exercise intervention for alcohol dependent patients (Brown et al., 2009). Results from this study suggest that, compared to the mean pretreatment percent days abstinent (PDA), significant increases in PDA were observed at the end of the 12-week exercise intervention and at the 3-month post-intervention follow-up.
Similar to alcohol treatment, there exists a lack of studies examining the role of exercise during drug abuse treatment (Donaghy & Ussher, 2005). In one small, uncontrolled pilot study of an exercise intervention conducted with substance abusing offenders in outpatient treatment, Williams (2000) conducted a 12-week intervention consisting of once weekly strength training groups plus recommendations for aerobic exercise during the rest of the week. While substance abuse outcomes were not presented in the results, the authors reported that the 11 out of 20 participants who completed the intervention reported that exercise was helpful in maintaining abstinence. In addition, exercise interventions have been applied with adolescent substance abusers. Collingwood and colleagues (Collingwood, Reynolds, Kohl, Smith, & Sloan, 1991) conducted a clinical trial of an 8–9 week structured fitness program with adolescent substance abusers. Adolescent participants showed improved physical fitness, reduced polysubstance use, and increased abstinence rates. Overall, there exists a lack of available studies attempting to evaluate the potential of exercise to benefit adults in treatment for drug use disorders. Stronger studies are needed to establish that exercise interventions should be more broadly implemented in practice.
The purpose of this study was to pilot test a 12-week moderate-intensity aerobic exercise intervention as an adjunct to treatment for drug dependent outpatients, as a preliminary step in a program of research. In this study, we examine the feasibility and exercise adherence among drug dependent patients. In addition, we examine drug use and cardiorespiratory fitness outcomes at the end of the 12-week intervention and at the 3-month follow-up.
Section snippets
Participants
Participants were recruited from an intensive alcohol and drug treatment partial-hospitalization program at a psychiatric hospital in the Northeast USA as well as through study advertisements in the local newspaper. Eligible participants: (a) were between 18 and 65 years of age, (b) met current DSM-IV criteria for drug dependence as assessed by the Structured Diagnostic Interview for DSM-IV (SCID-P), (c) were sedentary; i.e., have not participated regularly in aerobic physical exercise (for at
Treatment adherence
Attendance for each week of the exercise intervention is displayed in Fig. 1. During the 12-week intervention, participants attended an average of 8.6 (SD = 3.9) weekly exercise sessions. Over the course of the 12-week intervention, participants exercised an average of 3.9 (SD = 1.1) days per week. In addition, participants engaged in an average of 209 (SD = 180) minutes of physical activity per week with 147 (SD = 100) of these minutes being at an exertion level of at least moderate intensity.
Discussion
Relapse continues to pose a major problem to the substance abuse treatment field as a whole and to individuals attempting recovery from drug use disorders. Studies evaluating strategies to enhance maintenance of treatment gains have devoted relatively little attention to lifestyle modification, and research in the area of engaging in physical activity and recovery from drug use disorders is still in its infancy. For over two decades, researchers have called for studies examining the role of
Acknowledgments
Supported in part by grant DA14599 from the National Institute on Drug Abuse to Dr. Richard A. Brown.
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