Overview of Exercise in Treatment of Substance Use Disorders

Overview of Exercise in Treatment of Substance Use Disorders Richard A. Brown, Ph.D. Research Professor School of Nursing University of Texas at Austin

Acknowledgments Support provided by the National Institute on Drug Abuse (1RO1DA14599) and the National Institute on Alcohol Abuse and Alcoholism (1R01AA13418) Collaborators: Ana M. Abrantes, Ph.D. Jennifer P. Read, Ph.D. Bess Marcus, Ph.D. John Jakicic, Ph.D. David R. Strong, Ph.D. Julie Oakley, M.S. Susan E. Ramsey, Ph.D. Christopher Kahler, Ph.D. Gregory D. Stuart, Ph.D. Alan Gordon, M.D. Mary Ella Dubreuil, RN

Introduction The benefits of exercise on physical health are numerous and well-known There is agreement among scientific studies that sedentary lifestyles carry at least twice the risk of serious disease and premature death There is also a growing body of evidence that exercise is beneficial for psychological well-being Only recently has exercise been studied as a potential intervention for substance dependent individuals

Exercise for SUDs: State of the Science A recent, soon-to-be-published review noted that 14 exercise alcohol interventions have been published to date All but two lacked a control condition (i.e., not RCTs) or had serious methodological flaws Fewer exercise interventions for drug dependence have been published, with similar methodological limitations Overall, we can conclude that exercise interventions for SUDs are feasible and safe. A small number of studies suggest that regular exercise may be a useful adjunctive treatment for SUDs, however more well-controlled studies are needed

Relapse Prevention Rationale Despite some progress in the development of efficacious treatments for substance use disorders, relapse remains a major problem Attention to the problem of relapse has intensified over the years (Marlatt & Donovan, 2005; Moos & Moos, 2006) and the significant work of Marlatt and colleagues provide a social learning model of the relapse process and suggested treatment approaches Although Lifestyle Modification was one of the main components in Marlatt s relapse prevention model, this component has received the least emphasis in relapse prevention programs for alcohol and drug dependence Exercise represents a potentially useful and relatively unexplored alternative behavior for alcohol and drug recovery

Are Alcohol Dependent Patients Interested in Exercise? We conducted a study of alcohol dependent patients (n = 105) in our Butler Hospital ADP treatment setting The majority of patients (75%) expressed some interest in participating in an exercise program Almost half (47%) indicated that they were engaging in regular exercise (at least 20 minutes, 3 times weekly) Common barriers to physical exercise included: Cost of joining a gym Cost of exercise equipment Lack of motivation Not having enough time Transportation difficulties Read, Brown, Marcus et al. (2001). Journal of Substance Abuse Treatment

Why Might Exercise Be Helpful in Recovery? Reduced Depressive Symptoms Positive Mood States Without Use of Alcohol or Drugs Decreased Urges and Coping-Oriented Motives Improved Cognitive Functioning Improved Sleep

Exercise intervention for drug dependence The few available, mostly adolescent studies, suggest the potential for positive outcomes to be achieved with exercise interventions Research efforts are needed with adults to: develop standardized, exercise-based interventions for drug dependence apply sound methodology to the study of exercise interventions in this population The current study is intended to address this need by describing the development and evaluation of a moderate-intensity aerobic exercise program for drug dependent adults NIDA Behavioral Therapies Development Program (Stage I)

Study Aims The purpose of the study was to examine the feasibility and provide preliminary evidence for the efficacy of aerobic exercise as an adjunctive intervention for drug dependent individuals in early recovery

Eligibility Criteria INCLUSION: a) Between 18 and 65 years old b) Meeting diagnostic (DSM-IV) criteria for drug dependence c) Currently sedentary: Not participating in aerobic exercise (at least 20 min/day, 3 days/week) for the past 6 months d) Current drug dependence treatment (other than methadone maintenance) and/or weekly self-help participation e) In early recovery: Have used drug(s) in the past 90 days EXCLUSION: a) DSM IV (per SCID-P) diagnosis of bipolar disorder, anorexia, or bulimia nervosa b) History of psychotic disorder or current psychotic symptoms c) Current suicidality or homocidality d) Marked organic impairment e) Physical disabilities, medical problems or use of medications that would hinder participation in moderate intensity aerobic exercise f) Pregnant or planning to become pregnant

Components of Moderate Intensity Aerobic Exercise Intervention Aerobic exercise Incentive procedures Behavioral group to promote exercise adoption and maintenance

Aerobic Exercise Supervised 12 weekly exercise sessions at Butler Hospital supervised by an exercise physiologist Exercise on treadmills, recombinant bicycles, and elliptical machines. Exercise sessions started at 20 minutes per session: Gradually progressed to 40 minutes by week 12. Participants exercised at a moderate intensity level Independent Participants engage in aerobic activity 2-3 additional times per week on their own (e.g., walking the Boulevard, joining a gym) Participants kept exercise logs to record physical activity

Medical Clearance Medical clearance to participate consisted of: Physician review of medical history Submaximal graded treadmill test

Butler Hospital Fitness Facility Commercial quality exercise equipment 5 treadmills 3 recumbent bicycles 2 elliptical machines Mats for stretching, warm-up and cool-down Built-in stereo sound system

Incentive Procedures Why incentives? Incentive procedures : $5 for attending each weekly session $5 for returning completed exercise logs Fish bowl drawing ($10-$50) for attendance at consecutive weekly sessions Participants earned an average of $86 (SD=39) for weekly and $128 (SD=89) from the fishbowl drawing for attending consecutive weekly sessions

Cognitive-Behavioral Group Participants were guided as to how to increase overall fitness through behavioral changes in their daily lives Each of 12 group sessions focused on a certain topic designed to increase overall skill level and motivation resulting in improved exercise adoption and maintenance

Richard A. Brown, Ph.D. Jennifer Read, Ph.D. Ana M. Abrantes, Ph.D. Copyright 2003 by Richard A. Brown

Benefits of Exercise

Benefits of Exercise What benefits of exercise have you experienced in the past when you have exercised? Here are some of the benefits that people tell us they have experienced... What specific benefits do you think you will experience if you begin to exercise regularly and how important will they be to you?

Goal Setting

Goal Setting Setting and achieving goals is a skill that can be learned and takes practice. Short-term versus long-term goals Step by step: Using short-term goals to achieve long-term goals Goals should be: Yours Specific Measurable Attainable and realistic Planned Monitored

Recommended Goals: Start Slowly We recommend the following minimum goals for moderate intensity aerobic exercise: Weeks 1-4: at least 15 minutes, 3 times per week Weeks 5-8: at least 20 minutes, 3 times per week Weeks 9-12: at least 20 minutes, 4 times per week

Getting Motivated Staying Motivated

Exercise Enjoyment Aerobic dance Softball Badminton Snorkling Basketball Swimming Biking Tennis Canoeing/Kayaking Water aerobics Dancing Walking Ice skating Yoga Rock climbing Running

Other Ways to Motivate Yourself Positive self-statements Examples: I m doing something positive for my body My body is getting stronger each time I exercise Visualizing success Examples: Imagine yourself running a mile or taking a long walk with your kids Rewarding yourself Write down your intended reward for a specific goal and hold yourself to it

Getting Back on Track

Getting Back on Track Identify high-risk situations Examples: getting the flu, vacation, friends visiting from out of town, holidays Develop a plan for dealing with high-risk situations Seek support of others Re-examine or set new goals Use problem solving skills (I-Identify the problem, D-Develop a list of solutions, E-Evaluate your solutions, A-Analyze how well your plan worked) Avoid All-or-Nothing Thinking All-or-Nothing Thought: I m never going to be physically fit Positive Thought: It takes time and I ve already made some progress

Exercise and Mental Health

Exercise and Mental Health Self-concept refers to a sense of trust and belief in yourself Exercise has been shown to improve self-concept A brief demonstration of the effects of exercise on your mood: Mood rating: 10 = best mood 1 = lowest, most depressed or anxious Mood score before walk Mood score after walk What else did you notice about yourself after the walk?

Barriers: Identifying Them and Overcoming Them

Barriers The first step: Identifying barriers The second step: Cognitive and behavioral strategies Cognitive (thinking) strategies: Barrier Cognitive strategy Feeling tired Exercise will give me energy Even though I m tired now, if I get up and do something, I ll probably feel less tired Behavioral strategies: Barrier Behavioral strategy Feeling tired at the end Bring your gym bag to work and workout right after of the work day work rather than going home first Take 1/2 hour for lunch rather than 1 hour. Go for walk for the other 1/2 hour

Time Management

Time Management Prioritizing: Allows you to tackle the most important tasks first Make a To Do list and divide tasks into: Will do and Hope to do tasks Planning: Plan ahead to help you complete the Will do s and hopefully some of the Hope to do s

The Basics: What You Need to Know to Exercise Wisely

THE BASICS: Exercising Wisely Every U.S. adult should accumulate 30 minutes or more of moderate intensity exercise on most, preferably all, days of the week American College of Sports Medicine, 2001

What is Moderate Intensity Aerobic Exercise? Moderate intensity = 55-69% of heart rate max Heart rate max: Subtract... 220 - your age So... If you re 40 years old: Heart rate max = 220-40 = 180 55-69% of 180 = 99-124 beats per minute (bpm) Thus moderate intensity range = 99-124 bpm

The Benefits of Exercise for (Alcohol or Drug) Recovery

The Benefits of Exercise for (Alcohol or Drug) Recovery Psychological benefits of exercise Achieve pleasurable state without the use of drugs Positive set of alternative behaviors Improved coping Group activity that provides social support Physical health benefits of exercising

Maintenance

Maintenance Continue to seek support from others Engage in activities you like Try new activities Set new goals Think positively Look how far you ve come and how much you ve learned

Making Plans for Action

1. Stages of Change Precontemplation Contemplation Relapse Preparation Maintenance Action

Decisional Balance Costs of exercising Benefits of exercising

Getting Support

Getting Support STEP 1: Take a few moments to think about the people in your life. Who can be a support to you in your efforts to be more physically active? What kind of support can they provide?

Getting Support STEP 2: Let others know how they can be helpful to you Tell them what you have in mind Ask whether they will be able to provide this kind of support

Pilot Sample Characteristics N=19 recruited and medically cleared to begin intervention N=16 attended first exercise session Mean age: 38.3 years (SD=10.1) Gender: female 5 (31%) male - 11 (69%) Race: White 13 (81%) Black 2 (13%) Hispanic -1 (6%) Mean Yrs. of Education 12.5 (SD=1.4) Employment 9 full-time (56%) 4 part-time (25%) 3 unemployed (19%)

Pilot Sample Substance Use In the 3 months prior to beginning the intervention; 81.3% drank alcohol 31.3% used cocaine 31.3% used marijuana 12.5% used opiates 6.3% reported sedative use. In the one month prior to the intervention,63.7% of participants used two or more substances

Adjustments to Study Recruitment In pilot phase, a number of adjustment were made in inclusion criteria to attempt to increase enrollment Original plan was to recruit from Butler ADTS Partial Hospital Series of adjustment were made: Recruited another outpatient treatment site Media advertisements to general community to recruit participants Changed early recovery criteria from 6 weeks to 3 months Changed adjunctive treatment criteria to include self-help

Pilot Exercise Session Attendance Attendance at Exercise Session (n=16) Percent of Sample 100 90 80 70 60 50 40 30 20 10 0 1 2 3 4 5 6 7 8 9 10 11 12 Week

Pilot Exercise -- Drug Use Drug Use -- Percent Days Abstinence 100 Percent Days 80 60 40 End of Treatment t = 3.25, df = 14, p-value <.001 3-Month Follow-up t = 3.46, df = 14, <001 20 0 Baseline 1 2 3 4 5 6 Month

Pilot Exercise -- Alcohol Use Alcohol Use -- Percent Days Abstinence 100 80 Percent Days 60 40 20 0 Baseline 1 2 3 4 5 6 Month

Pilot -- Drug Use by Adherence Drug Use by Adherence to Exercise Program 100% 80% Percent Abstinent 60% 40% Non-Adherent (n=6) Adherent (n=10) 20% 0% Post-Treatment 3-Month Follow-up

Exercise Pilot -- Preliminary Findings Participants attended an average of 8.6 (SD=3.9) exercise sessions during the 12-week intervention At post-treatment, there were significant differences between those adherent to the program (>8 exercise sessions) vs. those non-adherent in terms of Frequency of alcohol use [F(1,14) = 12.12, p<.01], and Frequency of drug use [F(1,14) = 10.78, p<.01] Overall, 80% of non-adherent participants relapsed vs. 20% of adherent participants (chi sq = 11.5, df = 1, p <.001)

Summary and Conclusions - I Overall, there was very strong patient and treatment community interest in aerobic exercise as a means of recovery from drug dependence Although response to our recruitment efforts was considerable, the study procedures and nature of the intervention likely resulted in barriers to participation Among Group Exercise participants, the intervention: Was well-received Resulted in high rates of session attendance

Summary and Conclusions - II Participants in the Group Exercise intervention showed: Reduced % days of drug and alcohol use Decreased level of depressive symptoms Increased cardiorespiratory fitness and decreased % body fat Higher rates of session attendance led to improved outcomes

R.A. Brown et al. / Journal of Substance Abuse Treatment 47 (2014) 1 9

Study Hypotheses As an treatment adjunct for sedentary, alcohol dependent patients in early recovery, a 12-week group aerobic exercise intervention (AE) would be more effective than a brief advice to exercise (BA-E) comparison condition in reducing the quantity and frequency of alcohol use Regardless of intervention condition, higher levels of exercise at follow-up assessments would be associated with lower levels of alcohol use AE would yield greater improvements in depressive and anxiety symptoms relative to BA-E

Eligibility Criteria INCLUSION: a) Between 18 and 65 years old b) Meeting diagnostic (DSM-IV-TR) criteria for alcohol dependence c) Currently sedentary: (i.e., exercising less than 60 minutes per week for the past 6 months d) In early alcohol recovery (i.e., currently in alcohol treatment and abstinent from alcohol for less than 90 days) e) Medically cleared to engage in moderate intensity exercise by the study physician EXCLUSION: a) Non-alcohol, substance dependence (except nicotine dependence) b) Anorexia or bulimia nervosa c) Bipolar disorder d) History of psychotic disorder or current psychotic symptoms e) Current suicidality f) Marked organic impairment g) Physical disabilities, medical problems, or use of medications that would interfere with a program of moderate exercise h) current pregnancy or intent to become pregnant

Sample Characteristics N=49 participants; Analyses based on pts who completed 2/3 of self-report assessments (44/43 at 3 mo./6 mo. post-bsl.) N=20 recruited from Butler ADP; N=29 from the community Mean age: 44.37 years (SD=10.75) Gender: Female 22 (45%) Male - 27 (55%) Race: White 37 (76%) Mean Yrs. of Education 14.6 (SD=2.4) Current Alcohol Tx in Prior 90 days: Inpt/Day Hospital 69% AA/NA 67% Pharmacotherapy for alcohol use 53% Individual provider 73%

Brief Advice to Exercise (BA-E) Doctoral level clinical psychologist or an exercise physiologist informed participants that they had been medically cleared to begin a moderate exercise regimen Received a brief, 15 20 minute session on the psychological and physical benefits of exercise Also received public health recommendations for exercise frequency (ACSM, 2000), duration, and intensity A written handout to summarize the information was provided No incentives BA-E participants were given the average amount earned by participants in the AE condition

Primary Drinking Outcomes by Treatment During the treatment period, zero-inflated Poisson models for drinking days (χ2(2) = 170.28, p < 0.01) and heavy drinking days (χ2(2) = 116.98, p < 0.01) were each statistically significant. Results support a significant decrease in drinking days and heavy drinking days for participants in the AE relative to those in BA-E during treatment. This effect was not maintained during the 12-week follow-up (ps > 0.40).

Adherence to AE Intervention Participants attended an average of 8.44 (SD =4.12) of 12 sessions 9 of the 26 participants (35%) attended all 12 sessions 16 participants (62%) met our criteria for adherence (attended 8 or more of the exercise sessions) The average attendance and self-monitoring amount earned by AE participants was $60.77 (SD = 38.88); the average fishbowl amount paid to AE participants was $103.46 (SD = 73.81)

Drinking Outcomes by Exercise Level Was level of moderate-intensity exercise related to both drinking days and heavy drinking days regardless of treatment condition? Level of exercise was related to drinking days only during treatment (p <.01) Level of exercise was related to both drinking days and heavy drinking days at 12 week follow-up (ps <.01)

Level of Exercise X Treatment Interaction There were also significant interactions suggesting that the effects of exercise on the count of drinking days and heavy drinking days were stronger for AE than BA-E (ps < 0.01) during the treatment and follow-up periods That is, participants in AE who exercised more frequently had significantly fewer drinking days during treatment and fewer heavy drinking days during treatment and follow-up periods, compared to BA-E participants exercising at the equivalent level

Effects on Depression, Anxiety, and Self-efficacy There were no significant treatment differences between AE vs. BA-E in symptoms of depression, anxiety or self-efficacy for abstinence, either at the end of treatment or at 12 week follow-up Changes in symptoms of depression, anxiety, and self-efficacy were similar for those who were adherent vs. non-adherent to AE during treatment and the follow-up period

Summary and Conclusions I The group aerobic exercise intervention (AE) demonstrated efficacy in reducing alcohol use, compared to the brief advice to exercise (BA-E) intervention, although the beneficial effects depended on timeframe and treatment adherence Adherence in AE was relatively high and comparable to interventions in the general population. The group behavioral content and the incentive system likely play an important role In this study, there were no effects of the AE intervention on symptoms of depression, anxiety or self-efficacy for abstinence

Summary and Conclusions II Although the main effects of group exercise were limited to the treatment period, this was not true for adherent individuals in AE. Adherent AE participants reported significantly fewer drinking days, relative to those in BA-E, during the follow-up period.. This suggests that regular participation in a group intervention may have a lasting impact on alcohol abstinence, and highlights the importance of treatment adherence.

Potential advantages of exercise as an adjunct to SUD treatment Exercise offers the potential for improved health and wellness Exercise is cost-effective, flexible and accessible Exercise offers variety in forms of exercise (running, fitness videos, swimming, aerobics class), social context (alone vs. with others), and venue (home, local gym, outdoors, etc) Exercise has minimal negative side effects compared to pharmacotherapy Exercise may reduce negative affect and/or increase positive affect; important because the largest percentage of relapses occur in negative affect situations

Future Directions I Given the positive findings from the current preliminary trial, a larger study evaluating the efficacy of the AE intervention as an adjunct to outpatient alcohol treatment is warranted. Future studies may also choose a comparison group that allows investigation of the effects of exercise on alcohol use such as a contact control non-exercise group. Future studies should investigate the optimal types of exercise interventions best suited for individuals with substance use disorders

Future Directions II Efforts should be incorporated to reduce barriers to exercise program and to study participation and adherence Exercise apps and more scalable exercise interventions warrant investigation Exercise interventions could be more fully integrated into substance use treatment programs

Completed Treatment Studies Brown, R.A., Abrantes, A.M., Read, J.P., Marcus, B.H., Jakicic, J., Strong, D.R., Oakley, J.R., Ramsey, S.E., Kahler, C.W., Stuart, G., Dubreuil, M.E. & Gordon, A.A. (2009). Aerobic exercise for alcohol recovery: Rationale, program description, and preliminary findings. Behavior Modification, 33(2), 220-249. Brown, R.A., Abrantes, A.M., Read, J.P., Marcus, B.H., Jakicic, J., Strong, D.R., Oakley, J.R., Ramsey, S.E., Kahler, C.W., Stuart, G.L., Dubreuil, M.E., & Gordon, A.A. (2010). A pilot study of aerobic exercise as an adjunctive treatment for drug dependence. Mental Health and Physical Activity, 3, 27-34. Brown, R.A., Abrantes, A.M., Minami, H., Read, J.P., Marcus, B.H., Jakicic, J.M., Strong, D.R., Dubreuil, M., Gordon, A.A., Ramsey, S.E., Kahler, C.W., & Stuart, G.L. (2014). A preliminary, randomized trial of aerobic exercise for alcohol dependence. Journal of Substance Abuse Treatment, 47, 1-9.

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