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Designing a physical activity program for individuals with addictions

This is an excerpt from Physical Activity and Mental Health by Angela Clow & Sarah Edmunds.

The evidence points to the efficacy of physical activity interventions for use in treating addictive behaviours. However, implementation of behavior change in this population can present practitioners with specific challenges. This section discusses the suggestions for designing effective interventions for those with addictions based on the evidence reviewed so far as well as practical considerations.

Exercise Type, Frequency and Intensity

Most studies have promoted moderate-intensity cardiovascular-type exercise such as brisk walking for use in those with addictive behaviours. Some work also incorporates more vigorous activities such as running. Because individuals with addictions are often extremely sedentary, a programme of moderate-intensity activity is likely to be acceptable and safe. However, a progression to more vigorous exercise may be beneficial. For example, the only study that found a long-term benefit of exercise for smoking cessation entailed 30 to 40 min of vigorous exercise 3 times/wk for 12 wk (Marcus et al., 1999). Similarly, the single study that showed a long-term impact of exercise on alcohol abstinence involved 1 h of progressively vigorous exercise 5 days/wk for 6 wk (Sinyor et al., 1982). None of the trials reviewed compared the effects of vigorous-intensity and moderate-intensity exercise on abstinence rates. Experimental studies have compared the effects of bouts of moderate-intensity and vigorous-intensity exercise and have shown that both intensities are effective in the short term for reducing tobacco-withdrawal symptoms (Taylor et al., 2007).

The intensity of activity that an individual is capable of depends on initial level of fitness, medical condition and stage of recovery from addiction. Careful medical screening is vital. For example, those addicted to amphetamine or cocaine are often undernourished, and problem drinkers often have weak muscles. Such individuals may require nutrition advice. Ultimately, individuals will have preferences regarding types of exercise, and programmes should be tailored to these preferences (Abrantes et al., 2011; Everson-Hock et al., 2010). Some individuals may prefer noncardiovascular types of exercise, which may also be beneficial. Resistance (i.e., weight) training, yoga and isometric exercise have all been successfully piloted as aids for smoking cessation and need to be tested in larger trials (Ussher, Taylor & Faulkner, 2012).

Regarding frequency and volume of exercise, the findings from Marcus and colleagues (2005) suggest that abstaining smokers need to accumulate at least 110 min/wk of moderate-intensity activity to maintain abstinence; supervised exercise on 2 or 3 days/wk may be necessary in order to achieve this. Shorter bouts of exercise can be used on an as-needed basis in response to cravings, and longer scheduled bouts can be used to maintain positive mood, manage stress and prevent cravings from arising. Research has not yet addressed the optimum dose of exercise for assisting alcohol and drug rehabilitation.

Exercise Supervision

The majority of intervention studies have employed group-based supervised exercise. In smokers, exercise counselling alone did not increase exercise levels sufficiently (Ussher et al., 2003), and all the interventions that showed a significant impact on long-term abstinence from alcohol or smoking entailed supervised exercise. Among novice exercisers, an element of supervised exercise may be useful to ensure initial adoption of regular exercise and to provide information about safe exercise (e.g., warm-up) and exercise intensities (e.g., using heart rate monitors). Counselling toward pursuing home-based exercise is also likely to be important for encouraging patients to maintain exercise levels after the initial exercise programme ends.

Stages of Addiction Treatment

Early recovery from drug and alcohol dependence is a major transition that affects close relationships and employment and involves numerous treatment sessions. An exercise programme needs to complement these changes. Most exercise interventions discussed in this chapter have required patients to alter their substance- or alcohol-misuse behaviour and exercise behaviour simultaneously, yet it is not clear whether this is optimal. For some individuals the challenge of changing two health behaviours simultaneously may be too demanding. Also, it is not clear whether involvement in physical activity increases the motivation to manage substance intake or vice versa.

Among smokers, exercise has often been introduced in the studies discussed several weeks before an attempt to quit, thereby allowing people to adjust to the demands of increased exercise before starting to quit. This also allows exercise to play a role in managing cravings during the crucial early days of abstinence, when relapse rates are highest. Empirical work is required to determine the relative benefits of initiating exercise at different points in the addiction-treatment process. During later stages of treatment exercise may be useful for preventing relapse (e.g., by promoting an exercise identity that is incompatible with drug use). Studies are also needed to determine whether exercise can be used to increase substance abstinence among those who are not motivated to attempt abstinence.

Integrating Exercise With Standard Addiction Treatments

Greater integration of addiction and exercise programmes may enhance abstinence rates. For instance, rather than just proposing exercise as a means for getting fitter and managing weight, the practitioner could present exercise more as a self-control strategy for managing withdrawal symptoms and a way to address psychological and physical harms caused by addiction. Exercise could be used more in combination with pharmaceutical interventions. Whereas pharmaceutical interventions focus on reducing withdrawal symptoms (e.g., NRT), exercise could ideally be used to provide an added effect in client-led management of addictive symptoms.

Perceived Barriers to Exercise

Individuals with addictions are likely to have specific barriers to exercise, and these need to be determined. In the general population, use of cognitive - behavioural techniques is effective for overcoming perceived barriers and increasing exercise adherence. Few addiction studies have included cognitive - behavioural counseling. Techniques such as self-monitoring (e.g., diaries), goal-setting and relapse-prevention planning are commonly used. Also, pedometers are now commonly used as a motivational tool. These and other motivational aids (e.g., financial incentives) need to be tested with exercise interventions in addicted populations.

Interventions for Different Subgroups

Exercise interventions need to be tested among addicted populations who might especially benefit from such interventions. Given the high prevalence of addictions among people with mental illness and the established benefits of regular physical activity for mental health, research that examines the role that physical activity may play in this population is needed (Arbour-Nicitopoulos et al., 2011).

Exercise interventions might be particularly appealing to adolescents, and controlled trials with young people are needed. Addicted individuals who are overweight may have a need for weight-control interventions such as exercise; no trial has yet focussed on this population. Additionally, surveys suggest that a nonpharmaceutical intervention such as exercise is likely to appeal to pregnant smokers (Ussher at al., 2008). Finally, sex needs to be considered when planning an appropriate intervention. Some evidence shows that women often prefer walking and aerobics, whereas men have more interest in sport, running and strength training.

Evidence to Practice

• Both moderate- and vigorous-intensity exercise have been shown to be effective for reducing tobacco-withdrawal symptoms and cravings.
• Progressing from light- and moderate-intensity exercise (e.g., brisk walking) to more vigorous-intensity exercise is advisable.
• Careful medical screening is required, especially among those with long-term alcohol or drug dependence (e.g., for malnutrition).
• Exercise interventions should be tailored to individual preferences.
• Abstaining smokers should accumulate at least 110 min/wk of moderate-intensity exercise.
• Interventions involving supervised exercise on 2 or 3 days/wk are likely to be necessary to be effective in treating addictive behaviours.
• Exercise can be performed on an as-needed basis for managing cravings or in scheduled bouts.
• If the exercise programme is to assist with early withdrawal symptoms, it ideally needs to begin before abstinence is attempted.
• Participating in physical activity encourages individuals to adopt an identity as an exerciser, which is incompatible with using addictive substances.
• Perceived barriers to exercise need to be identified and addressed using cognitive - behavioural techniques.
• The intervention needs to be adapted to various subgroups (e.g., according to sex, body weight and mental health).

Summary

Drug, alcohol and tobacco addictions are growing global problems. Exercise has many benefits for physical and psychological health, and evidence convincingly shows that exercise is effective for managing cravings and withdrawal symptoms, particularly in smokers. Regular exercise fosters a healthy lifestyle and exercise identity that is largely incompatible with addiction, and individuals undergoing rehabilitation for addiction express interest in exercising more. Exercise interventions are inexpensive, can be easily integrated with existing addiction treatments and have minimal side effects compared with pharmacological treatments. This chapter demonstrates that exercise is a highly plausible adjunctive treatment for addictive behaviour and that exercise programmes can be readily disseminated. However, limited evidence currently supports the benefits of exercise for helping smokers quit or helping those with drug or alcohol dependence abstain. This lack of evidence can partly be explained by the small number of large RCTs that have been conducted, lack of knowledge about effective doses of exercise and limited attention to methods for maximizing exercise adherence. This area of research is in its infancy, and further well-designed trials are needed.

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