ReviewExercise training – A beneficial intervention in the treatment of alcohol use disorders?
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.
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2021, Addictive BehaviorsCitation Excerpt :The existing literature supporting physical interventions for sAUD includes narrative and systematic reviews as well as meta-analyses. These studies explore physical functioning of sAUD patients and the short-term and long-term effects of physical activity on neuropsychiatric and cognitive measures, behavioral variables, and alcohol drinking outcomes (Ashdown-Franks et al., 2019; Giesen, Deimel, & Bloch, 2015; Hallgren, Vancampfort, Giesen, Lundin, & Stubbs, 2017; Stoutenberg, Rethorst, Lawson, & Read, 2016 for reviews). Mechanisms underlying the impact of physical activity on substance use disorder, however, still need to be explored (Lynch, Peterson, Sanchez, Abel, & Smith, 2013 for a review).
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2019, International Review of NeurobiologyCitation Excerpt :In the same vein, Correia, Benson, and Carey (2005) reported a significant correlation between exercise interventions and reduced drinking among college students, however, the authors emphasized that adherence to the administered exercise programs was low and dropout rates were high, which according to Weinstock (2010) may render exercise programs for AUD rather inadequate. In a review by Stoutenberg et al. (2016), it was suggested that exercise interventions may be effective in addressing drinking problems, but only when personal and social influences were taken into account. The ultimate goal being to reduce alcohol intake, Weinstock, Petry, Pescatello, and Henderson (2016) used an alternative approach to the previously used exercise-based programs by evaluating the effectiveness of an 8-week exercise intervention in sedentary heavy drinking college students.