Elsevier

Drug and Alcohol Dependence

Volume 160, 1 March 2016, Pages 2-11
Drug and Alcohol Dependence

Review
Exercise training – A beneficial intervention in the treatment of alcohol use disorders?

https://doi.org/10.1016/j.drugalcdep.2015.11.019Get rights and content

Highlights

  • Exercise improves conditions, such as anxiety, stress, impulsivity, and depression.

  • Exercise increases self-efficacy and promotes socially supportive environments.

  • Few studies have examined the impact of exercise training on alcohol use disorders.

  • Residential programs may be an ideal location for integrating exercise training.

Abstract

Background

A growing body of evidence suggests that exercise training may have multiple beneficial effects in individuals with mental health or substance use disorders. Yet, relatively little knowledge exists regarding the benefits of exercise training to augment treatment for alcohol use disorders (AUDs).

Purpose

The purpose of this narrative review is to present a summary of the growing body of published literature supporting exercise training as a treatment strategy for individuals with AUDs. We will provide evidence on the myriad of ways in which exercise may exert a positive effect on AUD outcomes including stress, anxiety, impulsivity, and depression. Further, we will explore how these mechanisms share common neurobiological pathways. The role of exercise in enhancing the social environment and increasing individual self-efficacy to reduce excess and/or inappropriate alcohol consumption will also be discussed.

Discussion

We will conclude with a description of completed investigations involving exercise training and provide suggestions for next steps in this innovative field of study.

Introduction

Alcohol use disorders (AUDs) affect approximately 18 million people in the United States (Center for Behavioral Health Statistics and Quality, 2013), with nearly 88,000 deaths per year occurring from alcohol-related causes (Stahre et al., 2014). One in 10 deaths per year, as well as an average of 30 years of potential life lost, can be attributed to excessive drinking among working-age adults (CDC, 2014). Injuries, violence, risky sexual behavior, and fetal alcohol spectrum disorders can occur with short-term alcohol consumption, while long-term use can lead to increased anxiety and depression, unemployment, and is associated with cardiovascular and circulatory diseases (CDC, 2014, Shield et al., 2014). As such, AUDs are an important public health concern and necessitate effective treatment options to best help affected individuals.

A substantial level of attention has been dedicated to developing efficacious treatments for AUDs, including medication, behavioral therapy, and mutual-help groups, that can be offered in both outpatient treatment settings, as well as in short- and long-term residential treatment facilities (National Institute on Alcohol Abuse and Alcoholism, 2010). Treatments are often combined, such as behavioral and pharmacological therapy, to better help patients establish behavioral and coping strategies that aid in recovery and ameliorate persistent symptoms that increase vulnerability to relapse (Dolan et al., 2013). However, challenges still remain in providing efficacious, individualized treatment plans and outcomes vary according to the severity of the AUD and the patient's motivation to change (Bottlender et al., 2006). Given the complexities and shortcomings of current treatment strategies, further work is required to strengthen AUD treatment and seek out novel treatment options that increase engagement in substance-free behaviors (Wackernah et al., 2014, Correia et al., 2005).

Exercise training, primarily in the form of structured aerobic exercise, has been employed in the treatment of a number of addictive disorders including gambling, marijuana and stimulant drug use, and smoking (Marcus et al., 1999, Trivedi et al., 2011a, Trivedi et al., 2011b, Angelo et al., 2013). Several studies have shown that engaging individuals in exercise training programs prior to, or as a part of, their smoking cessation efforts positively impacts their short-term abstinence rates (Marcus et al., 1999, Bock et al., 2012). Those who exercised more frequently and/or intensely (Marcus et al., 2005), and were better able to maintain a stable body weight (Kawachi et al., 1996, Marcus et al., 1999, Farley et al., 2012) were more successful in their cessation efforts. Similarly, participation in a supervised 2-week exercise-training program reduced marijuana cravings and use in an adult population (Buchowski et al., 2011). Finally, exercise training in substance abuse treatment has been gaining greater levels of attention (Lynch et al., 2013). Pilot investigations involving substance users in outpatient treatment settings have demonstrated that exercise training leads to a significant increase in percent days abstinent (Brown et al., 2010) and decreased urges to use drugs (Roessler, 2010). Additionally, a large, multi-site randomized control trial investigating the impact of exercise training as an augmentation to stimulant abuse treatment in residential treatment centers is currently in progress (Trivedi et al., 2011a, Trivedi et al., 2011b, Stoutenberg et al., 2012).

Despite the need for more efficacious treatment strategies for individuals with AUDs, and the growing body of evidence of exercise training in other populations with mental health or substance use disorders, relatively little evidence exists regarding the direct impact of exercise training in the treatment of AUDs. While a recent meta-analysis by Wang et al. (2014) demonstrated that exercise training is an effective strategy in enhancing substance abuse outcomes in general, only three studies were included in their analyses that specifically examined exercise training as a part of for AUDs, two of which involved low-intensity yoga programs. This highlights the need for more high quality research investigations. With increasing knowledge regarding the impact of exercise training on mental health and several pathways related to AUDs, there is a need to summarize these benefits and demonstrate the potential utility of exercise training as a part of a comprehensive AUD treatment program. The purpose of this narrative review is to provide insight into the role of exercise training on several pathways related to AUDs including stress, anxiety, impulsivity, and depression, as well as their common neurobiological pathways. We will conclude with a description of completed investigations involving exercise training and alcohol use and provide suggestions for next steps in this innovative field of study.

Section snippets

Role of stress and anxiety in alcohol use disorders

Anxiety is a diverse and common comorbidity among individuals with AUDs (Wolitzky-Taylor et al., 2011). Data suggest that there is a significant, bi-directional relationship between anxiety disorders and excessive alcohol use (Kushner et al., 2000). Individuals with an anxiety disorder were 2.6 times more likely to have alcohol dependence, and more than a third of adults with alcohol dependence had at least one form of an anxiety or mood disorder (Grant et al., 2004, Teesson et al., 2009).

Role of impulsivity on alcohol use disorders

Impulsivity has been defined as a behavior that tends to be committed without forethought or conscious judgment and is characterized by acting on the spur of the moment with a lack of planning (Evren et al., 2012). Individuals with high impulsivity have a predisposition toward rapid, unplanned actions that are unduly risky, inappropriate, and often result in undesirable consequences (Moeller et al., 2001). Impulsivity is a multi-dimensional construct with individual differences occurring across

Role of depression in alcohol use disorders

Depression is among the psychiatric disorders most frequently associated with AUDs (Lai et al., 2015). Population-based surveys report that nearly one-third of individuals with an AUD have a history of major depression (Kessler et al., 1997), while estimates in clinical samples are over 40% (Miller et al., 1996, Schuckit et al., 1997). Similar to other disorders previously discussed, prospective analyses indicate a bi-directional relationship between AUDs and depressive disorders; those with an

Role of neurobiology in alcohol use disorders

Substantial research has examined the neurobiological mechanisms responsible for the development of AUDs. The synthesis and metabolism of dopamine (Engel and Jerlhag, 2014), serotonin (LeMarquand et al., 1994a, LeMarquand et al., 1994b) and gluccocorticoids (Stephens and Wand, 2012) have all been implicated in the development and recurrence of AUDs. These mechanisms appear to be responsive to acute consumption of alcohol and also have a role in alcohol craving and relapse. Alcohol consumption

Exercise, self-efficacy, and alcohol use disorders

Self-efficacy refers to the extent to which someone believes they are capable of successfully managing a challenging circumstance (Bandura, 1986). Applied to addictive behavior, self-efficacy can be understood as the extent to which the addicted individual views themselves as being able to cope with a difficult situation without relying on alcohol or other drugs. The self-efficacy construct is featured prominently in models of addiction as an important etiological mechanism (Maisto et al., 1999

Exercise and the social environment for individuals with alcohol use disorders

In addition to the direct effects that exercise may have on factors such as mood or craving, exercise also may act on other, more distal factors that have a positive influence on AUD outcomes. Most notable among these are the effects that exercise may have on an individual's social environment. The social environment is one of the strongest predictors of alcohol and other drug involvement (Laudet et al., 2002, Bischof et al., 2007, Longabaugh et al., 2010) and has been posited to be a critical

Animal models of exercise training and alcohol consumption

Animal models are commonly used to examine the impact of exercise training on alcohol use and associated mediating factors. Chronic exercise has been shown to alleviate stress-produced anxiety- and depression-like behavior (Kim and Leem, 2014). Other studies have demonstrated that C57BL/6IBG mice (a genetic strain that willingly seeks and consumes higher levels of ethanol) alter their alcohol consumption patterns when given unlimited access to a running wheel over several days as compared to

Direct effect of exercise training on alcohol consumption and alcohol use disorders

While several investigators have examined integrating exercise as a part of AUD treatment, few have reported its direct impact on alcohol-related outcomes in humans (Frankel and Murphy, 1974, Palmer et al., 1988). One of the first studies to provide evidence of the potential impact of exercise training in alcohol treatment was conducted by Sinyor et al. (1982). Their study, involving 58 individuals attending a 6-week in-patient treatment program, engaged patients in a daily 1 h of physical

Future directions

The information presented in this review provides a rationale for the potential efficacy of exercise in the treatment of AUDs. However, direct evidence of the efficacy of exercise as an intervention in AUD treatment is limited and randomized controlled trials involving exercise training in individuals with substance use disorders are extremely rare (Zschucke et al., 2012). To our knowledge, no study has investigated the efficacy of exercise training in alcohol treatment in a controlled

Conclusion

The behavioral, neurobiological, and psychological disorders discussed in this paper rarely occur in isolation and are often seen in combination, amplifying their overall impact on AUDs. Furthermore, among substance users and individuals with AUDs, quality of life is generally very poor (Smith and Larson, 2003, Donovan et al., 2005). The proven ability of exercise to successfully to impact quality of life is an additional benefit of exercise training and may increase commitment to abstinence (

Role of funding source

Nothing declared.

Contributors

All authors directly contributed to the writing and editing of this manuscript.

Conflict of interest

Mark Stoutenberg is a consultant to Exercise is Medicine®, a program of the American College of Sports Medicine, which receives funding from The Coca-Cola Company and Technogym.

Acknowledgements

Mark Stoutenberg is supported by Grant Number 1KL2TR000461 of the Miami Clinical and Translational Science Institute from the National Center for Advancing Translational Sciences and the National Institute on Minority Health and Health Disparities. Chad D. Rethorst is supported by NIMH K01MH097847. The contents of this manuscript are solely the responsibility of the authors and do not represent the official views of the NIH.

References (200)

  • J.M. de Castro et al.

    Operantly conditioned running: effects on brain catecholamine concentrations and receptor densities in the rat

    Pharmacol. Biochem. Behav.

    (1985)
  • R.K. Dishman et al.

    Decline in cardiorespiratory fitness and odds of incident depression

    Am. J. Prev. Med.

    (2012)
  • S.L. Dolan et al.

    Urge-specific and lifestyle coping strategies of alcoholics: relationships of specific strategies to treatment outcome

    Drug Alcohol Depend.

    (2013)
  • G. Dom et al.

    Differences in impulsivity and sensation seeking between early-and late-onset alcoholics

    Addict. Behav.

    (2006)
  • G.F. Dunton et al.

    Social and physical environments of sports and exercise reported among adults in the American Time Use Survey

    Prev. Med.

    (2008)
  • M.A. Ehringer et al.

    Reduced alcohol consumption in mice with access to a running wheel

    Alcohol

    (2009)
  • J.A. Engel et al.

    Alcohol: mechanisms along the mesolimbic dopamine system

    Prog. Brain Res.

    (2014)
  • M. Galanter

    Spirituality and recovery in 12-step programs: an empirical model

    J. Subst. Abuse Treat.

    (2007)
  • E.S. Giesen et al.

    Clinical exercise interventions in alcohol use disorders: a systematic review

    J. Subst. Abuse Treat.

    (2015)
  • P.E. Gilliam et al.

    The effects of exercise training on [3H]-spiperone binding in rat striatum

    Pharmacol. Biochem. Behav.

    (1984)
  • B.N. Greenwood et al.

    Wheel running alters serotonin (5-HT) transporter, 5-HT1A, 5-HT1B, and alpha 1b-adrenergic receptor mRNA in the rat raphe nuclei

    Biol. Psychiatry

    (2005)
  • B.N. Greenwood et al.

    Long-term voluntary wheel running is rewarding and produces plasticity in the mesolimbic reward pathway

    Behav. Brain Res.

    (2011)
  • S. Hattori et al.

    Striatal dopamine turnover during treadmill running in the rat: relation to the speed of running

    Brain Res. Bull.

    (1994)
  • A. Heinz et al.

    Hypothalamic-pituitary-gonadal axis, prolactin, and cortisol in alcoholics during withdrawal and after three weeks of abstinence: comparison with healthy control subjects

    Psychiatry Res.

    (1995)
  • M.P. Heyes et al.

    Nigrostriatal dopaminergic activity is increased during exhaustive exercise stress in rats

    Life Sci.

    (1988)
  • M.G. Kushner et al.

    The relationship between anxiety disorders and alcohol use disorders: a review of major perspectives and findings

    Clin. Psychol. Rev.

    (2000)
  • H.M. Lai et al.

    Prevalence of comorbid substance use, anxiety and mood disorders in epidemiological surveys, 1999–2014: a systematic review and meta-analysis

    Drug Alcohol Depend.

    (2015)
  • A. Abramovitch et al.

    Correlates of physical activity with intrusive thoughts, worry and impulsivity in adults with attention deficit/hyperactivity disorder: a cross-sectional pilot study

    Isr. J. Psychiatry Relat. Sci.

    (2013)
  • A.M. Abrantes et al.

    A preliminary randomized controlled trial of a behavioral exercise intervention for smoking cessation

    Nicotine Tob. Res.

    (2014)
  • B. Adinoff et al.

    Disturbances of the stress response: the role of the HPA axis during alcohol withdrawal and abstinence

    Alcohol Health Res. World

    (1998)
  • B. Adinoff et al.

    Suppression of the HPA axis stress-response: implications for relapse

    Alcohol. Clin. Exp. Res.

    (2005)
  • B. Adinoff et al.

    Dissection of hypothalamic-pituitary-adrenal axis pathology in 1-month-abstinent alcohol-dependent men. Part 2: Response to ovine corticotropin-releasing factor and naloxone

    Alcohol. Clin. Exp. Res.

    (2005)
  • F.J. Aidar et al.

    The influence of resistance exercise training on the levels of anxiety in ischemic stroke

    Stroke Res. Treat.

    (2012)
  • D.L. Angelo et al.

    Evaluation of a physical activity program for pathological gamblers in treatment

    J. Gambl. Stud.

    (2013)
  • R.M. Anthenelli et al.

    Stress hormone dysregulation at rest and after serotonergic stimulation among alcohol-dependent men with extended abstinence and controls

    Alcohol. Clin. Exp. Res.

    (2001)
  • T.R. Apodaca et al.

    Effect of a significant other on client change talk in motivational interviewing

    J. Consult. Clin. Psychol.

    (2013)
  • A.L. Baker et al.

    Randomized controlled trial of cognitive-behavioural therapy for coexisting depression and alcohol problems: short-term outcome

    Addiction

    (2010)
  • D. Baldwin et al.

    The role of serotonin in depression and anxiety

    Int. Clin. Psychopharmacol.

    (1995)
  • A. Bandura

    Social Foundations of Thought and Action: A Social Cognitive Theory

    (1986)
  • J.B. Bartholomew et al.

    Effects of acute exercise on mood and well-being in patients with major depressive disorder

    Med. Sci. Sports Exerc.

    (2005)
  • W.K. Bickel et al.

    The behavioral economics of substance use disorders: reinforcement pathologies and their repair

    Annu. Rev. Clin. Psychol.

    (2014)
  • G. Bischof et al.

    Stability of subtypes of natural recovery from alcohol dependence after two years

    Addiction

    (2007)
  • J.A. Blumenthal et al.

    Exercise and pharmacotherapy in the treatment of major depressive disorder

    Psychosom. Med.

    (2007)
  • B.C. Bock et al.

    Yoga as a complementary treatment for smoking cessation in women

    J. Womens Health

    (2012)
  • I. Boileau et al.

    Alcohol promotes dopamine release in the human nucleus accumbens

    Synapse

    (2003)
  • J. Bolton et al.

    Use of alcohol and drugs to self-medicate anxiety disorders in a nationally representative sample

    J. Nerv. Ment. Dis.

    (2006)
  • M. Bottlender et al.

    The effectiveness of psychosocial treatment approaches for alcohol dependence – a review

    Fortschr. Neurol. Psychiatr.

    (2006)
  • M. Bottlender et al.

    Impact of craving on alcohol relapse during, and 12 months following, outpatient treatment

    Alcohol Alcohol.

    (2004)
  • M.S. Buchowski et al.

    Aerobic exercise training reduces cannabis craving and use in non-treatment seeking cannabis-dependent adults

    PLoS ONE

    (2011)
  • J.W. Buckholtz et al.

    Dopaminergic network differences in human impulsivity

    Science

    (2010)
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