An overview of studies on exercise for Substance Use Disorders treatment connected to the misuse of illegal drugs

Abstract

Several types of Substance Use Disorders (SUDs) treatment include physical exercise as an add-on recovery. This review summarizes research on sports and physical exercise as an adjunct to SUDs treatment with the misuse of illegal drugs. Twenty peer-reviewed papers that met the inclusion criteria for representing cross-sectional, intervention and, review studies were considered. Descriptives for each category are presented as well as synthesized findings regarding outcomes and preferences of patients with SUDs, regarding physical exercise programs. Further, the studies are discussed in terms of quality, quantity, and positive outcomes of physical activity for patients with SUDs. Finally, information regarding the design of sports and physical exercise programs is critically presented and discussed.

Full text

01
An overview of studies on exercise for
Substance Use Disorders treatment
connected to the misuse of illegal drugs
Plus
February, 2021

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Studies on exercise for SUDs treatment connected to the misuse of illegal drugs
Editorial Advisor Group
Hassandra Mary
Assistant professor of Department of Physical Education and Sport Science, University of Thessaly, Greece.
Theodorakis Yiannis
Professor of Department of Physical Education and Sport Science, University of Thessaly, Greece
Goudas Marios
Professor of Department of Physical Education and Sport Science, University of Thessaly, Greece
Papaioannou Athanasios
Professor of Department of Physical Education and Sport Science, University of Thessaly, Greece
Panagiotounis Fotis
Department of Education, Therapy Centre for Depended Individuals (KETHEA), Greece
Acknowledgements
This document would not have been possible without the contribution of the post-graduate students of the
University of Thessaly, Chouleva Thomai and Aarthi Nadagopal.

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Studies on exercise for SUDs treatment connected to the misuse of illegal drugs
Contents
Abstract ............................................................................................................................................................................................ 5
Chapter 1 | Introduction ............................................................................................................................................................ 6
Why do people take drugs? ........................................................................................................................................................ 6
Risk and Protective Factors for Drug Use .............................................................................................................................. 7
Substance use disorders (SUDs) .............................................................................................................................................. 7
Addiction .......................................................................................................................................................................................... 7
Addiction and Health .................................................................................................................................................................... 8
Addiction and personality ............................................................................................................................................................ 8
Substance use disorders treatment ........................................................................................................................................ 8
Physical exercise and SUDs treatment ................................................................................................................................... 9
Aim of the review .......................................................................................................................................................................... 9
Chapter 2 | Method .................................................................................................................................................................. 10
Inclusion and Exclusion Criteria ............................................................................................................................................. 10
Information sources .................................................................................................................................................................. 10
Search Strategy ........................................................................................................................................................................... 10
Study selection ............................................................................................................................................................................ 10
Data extraction process ........................................................................................................................................................... 10
Data items .................................................................................................................................................................................... 11
Chapter 3 | Results .................................................................................................................................................................. 12
Descriptives of Cross-sectional studies .............................................................................................................................. 12
Descriptives of Intervention studies ..................................................................................................................................... 12
Behavior Change techniques .................................................................................................................................................. 13
Descriptives of Literature reviews ........................................................................................................................................ 14
Synthesized Outcome Findings .............................................................................................................................................. 14
Outcomes of physical exercise interventions and reviews ............................................................................................ 15
Chapter 4 | Discussion ............................................................................................................................................................ 16
Available research regarding physical exercise for individuals under SUDs treatment ...................................... 16
Outcomes of physical exercise ............................................................................................................................................... 16
Designing physical exercise interventions for SUDs treatment connected to the misuse of illegal drugs
...... 17
Behavior change and motivational techniques used at the intervention groups of eective studies .............. 17
Physical exercise characteristics ........................................................................................................................................... 17
Limitations ................................................................................................................................................................................... 18
Conclusion .................................................................................................................................................................................... 18

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Studies on exercise for SUDs treatment connected to the misuse of illegal drugs
Abstract
Several types of Substance Use Disorders (SUDs) treatment include physical exercise as an add-on recovery.
This review summarizes research on sports and physical exercise as an adjunct to SUDs treatment with the
misuse of illegal drugs. Twenty peer-reviewed papers that met the inclusion criteria for representing cross-
sectional, intervention and, review studies were considered. Descriptives for each category are presented as
well as synthesized ndings regarding outcomes and preferences of patients with SUDs, regarding physical
exercise programs. Further, the studies are discussed in terms of quality, quantity, and positive outcomes
of physical activity for patients with SUDs. Finally, information regarding the design of sports and physical
exercise programs is critically presented and discussed.
Keywords: physical exercise, SUDs, intervention development.
Glossary
Abbreviation Description
RTS+ Reintegration Through Sport Plus
SUDs Substance Use Disorders
PE Physical Exercise
BCTs Behavior Change Techniques

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Studies on exercise for SUDs treatment connected to the misuse of illegal drugs
Chapter 1 Introduction
Drug use is one of the most serious problems in modern-day public health and society as a whole, with
a signicant proportion of young adults in developed countries, have used an illicit drug at some point in
their lives. Drug use aects the brain’s «reward circuit,» causing euphoria as well as ooding the brain with
the chemical messenger “dopamine”. Surges of dopamine in the reward circuit cause the reinforcement of
pleasurable but unhealthy behaviors leading people to repeat the behavior again and again. These brain
adaptations oen lead to the person becoming less and less able to derive pleasure from other things they
once enjoyed (NIDA, 2018). Consequently, drug use is bound to impact individuals’ health and well-being. The
health consequences of drug use may include a range of negative outcomes such as substance use disorders,
mental health disorders, HIV infection, hepatitis-related liver cancer and cirrhosis, overdose, and premature
death (World Drug Report, 2020). Drug use, particularly when it develops into substance use disorders, can
also have an impact on the social development of the users. Besides, long-term use also causes changes
in other brain chemical systems and circuits, aecting functions that include learning, judgment, decision-
making, memory, and behavior (NIDA, 2018).
➤ Why do people take drugs?
According to NIDA (2020), people begin taking drugs for a variety of reasons, amongst which:
- To feel good. Most abused drugs produce intense feelings of pleasure. This initial sensation of euphoria is
followed by other eects, which dier depending on the type of drug used. For example, when it comes to
stimulants such as cocaine, the state of feeling “high” is assorted with feelings of power, self-condence, and
increased energy. In contrast, the euphoria caused by opiates such as heroin is bound to induce feelings of
relaxation and satisfaction.
- To feel better. Certain people suering from social anxiety, stress-related disorders, and depression begin
abusing drugs in an attempt to alleviate feelings of distress. Stress can play a major role in starting the use of
drugs, continuing drug abuse, or relapsing when it comes to patients recovering from addiction.
- To do better. Some people feel pressure towards chemically enhancing or improving their cognitive or
athletic performance, which can play a role in initial experimentation and continued abuse of drugs such as
prescription stimulants or anabolic/androgenic steroids.
- Curiosity and “because others are doing it.” In this respect, adolescents are particularly vulnerable because
of the strong inuence of peer pressure. Teens are more likely than adults to engage in risky or daring
behaviors, to impress their friends, and express their independence from parental and social rules.
In 2018, an estimated 269 million people worldwide had used drugs at least once in the previous year. This
corresponds to 5.4% of the global population aged 15–64, representing nearly 1 in every 19 people. Over the
period 2009–2018, the estimated number of past-year users of any drug globally increased from 210 million
to 269 million. Consequently, the prevalence of drug use increased from 4.8% of the adult population in 2009
to 5.4 % in 2018 (World Drug Report, 2020).

Studies on exercise for SUDs treatment connected to the misuse of illegal drugs
Chapter 1
07
➤ Risk and Protective Factors for Drug Use
The likelihood of developing an addiction diers from person to person whereas no single factor determines
whether a person will become addicted to drugs. In general, the more risk factors present in a person, the
greater the chance that taking drugs will lead such person to drug use and addiction. Protective factors, on
the other hand, reduce a person’s risk. Risk and protective factors may be either environmental or biological
(NIDA, 2020).
RISK FACTORS PROTECTIVE FACTORS
Aggressive behavior in childhood Self-ecacy (belief in self-control)
Lack of parental supervision Parental monitoring and support
Low peer refusal skills Positive relationships
Drug experimentation Extracurricular Activities
Availability of drugs at school School anti-drug policies
Community poverty Neighborhood resources
Source: NIDA (2020)
➤ Substance use disorders (SUDs)
According to the Diagnostic and Statistical Manual of Mental Disorders (DSM–5) of the American Psychiatric
Association (2018), substance use disorders (SUDs) are dened as the persistence of drug use (including
alcohol) despite substantial harm and adverse consequences. SUDs are characterized by an array of mental/
emotional, physical, and behavioral problems such as chronic guilt, an inability to reduce or stop consuming the
substance(s) despite repeated attempts; driving while intoxicated; and physiological withdrawal symptoms.
The diagnoses of substance abuse and substance dependence were merged into the category of SUDs
(Guha, 2014; Hasin et al., 2013). The syndrome of dependence may be present for a specic psychoactive
substance (e.g. tobacco, alcohol, or diazepam), or a class of substances (e.g. opioid drugs), or a wider range
of pharmacologically dierent psychoactive substances (WHO, 2008).
Substance use disorders usually coexist with other mental illnesses; however, it is not clear whether one is
the cause of the other or whether common underlying risk factors have contributed to both disorders. The
relevance of comorbidity to substance use and mental health disorders is associated with lower treatment
success rates (EMCDDA, 2015).
➤ Addiction
One severe substance use disorder is addiction. Addiction is a chronic disease character-
ized by drug seeking and use that is compulsive, or dicult to control, despite harmful
consequences. The initial decision to take drugs is voluntary for most people, but
repeated drug use can lead to brain changes that challenge an addicted person’s
self-control and interfere with their ability to resist intense urges to take drugs.
These brain changes can be persistent, which is why drug addiction is considered a
«relapsing» disease—people in recovery from drug use disorders are at increased
risk for returning to drug use even aer years of not taking the drug (NIDA, 2018).

Studies on exercise for SUDs treatment connected to the misuse of illegal drugs
Chapter 1
08
➤ Addiction and Health
People who suer from addiction oen have one or more accompanying medical issues, which may include
lung or cardiovascular disease, stroke, cancer, HIV/AIDS, Hepatitis B and C, and mental disorders. Imaging
scans, chest X-rays, and blood tests show the damaging eects of long-term drug abuse throughout the body.
For example, research has shown that tobacco smoke causes cancer of the mouth, throat, larynx, blood,
lungs, stomach, pancreas, kidney, bladder, and cervix. Besides, some drugs of abuse, such as inhalants, are
toxic to nerve cells and may damage or destroy them either in the brain or the peripheral nervous system
(NIDA, 2020).
➤ Addiction and personality
According to EMCDDA (2004), drug users suer from mental and personality disorders. Between 50% and
90% of drug users are reported to suer from personality disorders and around one-h (15–20%) from more
serious psychotic complaints. Depression and anxiety exist in addicts at greater levels than in other groups
(Craig, 1979; McIntosh & Ritson, 2001) as well as higher neuroticism (Kotov, et al., 2010; Zilberman et al.,
2018). Addicts are oen hostile individuals tending to have less control over their angry feelings (De Mojá &
Spielberger, 1997). Addicts pursue more sensation-seeking experiences and are characterized by impulsivity
(Zuckerman, 1979). Moreover, most addicts feature such traits as pursuing immediate gratication, a lack of
impulse control, demanding attention, low frustration tolerance, impatience, poor socialization, diculty in
proting from experience, being disrespectful of authority, having diculty in forming relationships, irritability,
and irresponsibility, and having underlying feelings of insecurity and inadequacy (Craig, 1979).
➤ Substance use disorders treatment
In recent years, our understanding of addiction and the wider range of substance use disorders has improved
signicantly, enabling us to respond eectively. Numerous mechanisms underlying addiction have been
discovered, having, in turn, spawned a multitude of models, each of which addresses a part of the problem.
A large number of addiction models have been proposed that describe such mechanisms, on which recovery
interventions and strategies are based (EMCDDA, 2013). SUDs can be treated eectively in most cases,
provided people have access to a wide range of services, based on behavioral and medicinal approaches
(NIDA, 2018).
However, it is a generally accepted assumption that SUDs treatment is a process of behavioral change
through which addicted persons are supported in their eorts to regain their physical and psychological
health and wellbeing whilst aspiring to the reinstatement of their social functioning (NIDA, 2017). In this
frame, the application of psychosocial interventions is used in treatment to address motivational, behavioral,
psychological, and other psychosocial factors related to SUDs. These interventions have proved eective
in reducing drug use, promoting abstinence, and preventing relapse (WHO & UNODC, 2020). Psychosocial
interventions are structured to address SUDs by helping patients to recognize the triggers for substance use
and learn alternative strategies to handle those triggers (Jhanjee, 2014; EMCDDA, 2016; Murthy, 2018).
In this context, interventions based on physical exercise-PE (i.e. exercise and sports) can help SUDs patients,
discover and develop strategies, which can support recovery and social reintegration (WHO & UNODC, 2020).
The contribution of physical exercise and sports seems to be crucial in a wide range of long-term benets
for the mental and physical health of SUDs patients. However, there is no extensive literature on the eects
of physical exercise as an eective intervention strategy in the treatment of SUDs connected to the misuse of
illegal drugs, with the majority of studies suering shortcomings and limitations.

Studies on exercise for SUDs treatment connected to the misuse of illegal drugs
Chapter 1
09
➤ Physical exercise and SUDs treatment
Physical exercise is characterized as a planned, organized, and repeated body movement that aims to promote
or maintain physical tness (Caspersen et al., 1985). Dierent types of SUDs treatment approaches include
physical exercise as an add-on therapy. Studies have reported benets when individuals in SUDs treatment
programs exercise regularly. Positive outcomes reported in studies include:
• Reduced drug intake
• Increased abstinence rate
• Reduced cravings during treatment
• Enhanced healing eects on SUDs
• Higher completion rate of the rehabilitation program,
• Relapse prevention
• Alleviation of a number of the factors that contribute to SUDs development and which act as barriers to
healthy recovery (e.g., a lack of social support, poor mental health, high stress, and boredom)
• Achievement of ‘holistic’ goals within treatment programs (e.g., improving interpersonal relationships, and
physical and mental health)
• Repair of the damage caused to the muscles and the cardiovascular system and helping the body to recover
from drug use complications faster
• Reduced anxiety depressive symptoms and enhanced mood states
• Improved self-condence, self-esteem, and body image
• Improved general well-being and quality of life
• Adoption of a healthy lifestyle that is incompatible with substance abuse
• Awareness of one’s health condition
• Reported increased personal satisfaction through physical and mental improvement, hence the completion
of one’s transformation.
Nevertheless, some studies did not detect targeted benets from exercise programs (McDaniel, 2016). Since
this review aims to inform the development of exercise training programs to be implemented by professionals
of drug treatment organizations, we consider it of importance to summarize the existing knowledge with a
broader focus on the existing literature in terms of outcomes and process on how physical exercise has been
applied and understood to relate to SUDs treatment. This review will focus on questions: Who can deliver the
physical exercise programs? What activities are best (if any)? How to design physical exercise programs for
SUDs? What factors should be taken into account?
➤ Aim of the review
The purpose of this review is to explore previous research regarding sports and physical exercise for SUDs
treatment connected to the misuse of illegal drugs (interventions, cross-sectional studies, and literature reviews).
The guiding research questions are as follows:
•
What research is currently available regarding sports, physical activity, or physical exercise programs related
to people who are under SUDs treatment?
• What are the preferences and/or attitudes of those with SUDs regarding sports, physical activity, or exercise?
• What are the outcomes of sport and physical exercise interventions on individuals under SUDs treatment?
• Which behavior change-inducing and motivational techniques were employed in respective studies that
showed positive outcomes

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Studies on exercise for SUDs treatment connected to the misuse of illegal drugs
Chapter 2 Method
➤ Inclusion and Exclusion Criteria
Studies were included if they met the following criteria: a. The participants should be aged between 15 and 60
years and in illicit drug addiction therapy, b. any type of physical activity, exercise, or sport, c. language should
be English. d. Prevention programs employing sport or exercise were excluded.
➤ Information sources
The database search was performed in two main databases: EBSCO and SCOPUS. The databases were
searched until May 2020. Included were only published studies from peer-reviewed journals. Journals from
various disciplines were considered. Publications in the English language were considered for the review.
Relevant references were also searched for possible handpicked suitable studies.
Overall, the authors of 8 articles were contacted to receive various clarications or to provide us with the full
papers, required for the review. Five authors replied to the initial request. The rest of the authors did not reply
to emails and reminders.
➤ Search Strategy
The database search was performed using selected keywords. Four groups of keywords were used, incorporating
such categories as “illicit drug”, “physical activity (exercise, sports)”, intervention”, “review” and “addiction therapy”.
➤ Study selection
The studies were selected based on the above-mentioned exclusion criteria. The search results were
reviewed by two independent reviewers. Both reviewers were trained well acquainted with the criteria. In
case of disagreement, a third reviewer was consulted until an agreement was reached. During the rst stage,
studies were excluded based on title and abstract whereas the rest of the studies were reviewed in full text.
➤ Data extraction process
Aer piloting a data extraction sheet (with 3 random studies) and rening it, the most important qualitative
and quantitative data from the studies were extracted. Descriptions of the interventions were coded according
to behavior change techniques (BCT) taxonomy as developed by Michie et al., (2013).
In order to be able to retrieve all the necessary information about the intervention contents or any other
information, we had to consult articles related to the chosen studies, such as, for example, protocols or
qualitative analyses. Five additional articles were consulted for this purpose (Dolezal, 2013; Nygard, 2018;
Zhu, 2016, 2018; Wang, 2017).

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Studies on exercise for SUDs treatment connected to the misuse of illegal drugs
Chapter 2
➤ Data items
Information was extracted from each study depending on the type of study. From cross-sectional studies we
extracted the following information:
a. Aim
b. No of participants
c. Type of Illicit drug
d. Type of Exercise/Sport/Physical Activity
e. Relevant Measures/assessments
f. Results/Outcomes
Appendix 1 presents all data extracted for cross-sectional studies.
From intervention studies we extracted the following information:
a. Aim
b. No of participants per group
c. Type of Illicit drug
d. Exercise (type/intensity/duration)
e. Measures/assessments (relevant variables that have been assessed)
f. BCT coding based on intervention description
g. Results / Outcomes
h. Type of delivery of exercise/sport/physical activity
i. Who delivered the exercise
j. Individual or Group exercise sessions
k. Setting
Descriptions of the interventions were coded according to the Behavior Change Techniques taxonomy (Michie
et al., 2013). BCT is a “systematic procedure included as an active component of an intervention designed
to change behavior”. These techniques, being an active component in behavior change interventions, have
distinct characteristics such as being observable, replicable, and irreducible. Michie and colleagues (2013)
developed a BCT taxonomy that allows identifying and coding various BCTs according to strict categories in
dierent interventions.
Appendix 2 includes all data extracted for intervention studies.
From review studies we extracted the following information:
a. Type of review
b. Aim
c. Number of included studies
d. Geographic areas
e. Inclusion criteria
f. Type of Illicit drug
g. Types of exercise/sport/physical activity
h. Results/Outcomes
Appendix 3 includes all data extracted for review studies.

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Studies on exercise for SUDs treatment connected to the misuse of illegal drugs
Chapter 3 Results
The title and abstract of 393 papers (187/EBSCO and 206 Scopus) were initially reviewed aer removing
duplicates. Aer reviewing the title and the abstracts, 320 papers were excluded (reasons: acute exercise only
eects, animal studies, prevention studies, etc). Finally, aer reviewing 73 full papers, 20 papers fullled the
inclusion criteria and data extraction started. These represented cross-sectional, intervention, and review papers.
➤ Descriptives of Cross-sectional studies
The cross-sectional studies gathered information from 959 participants in total. As of all studies, data were collected
from participants using mixed substances (illicit drugs, nicotine, and alcohol) whereas an investigation was
carried out with respect to regular physical exercise involvement of any type and intensity, checking whether
such practices were in accordance with the ocial guidelines. Four of the studies (Caviness 2013; Linke, 2015;
Nani, 2017; Wang, 2019) assessed physical exercise behavior among other measures whilst one assessed
only their motives to participate in exercise (Abrantes, 2011).
➤ Descriptives of Intervention studies
Two intervention studies (Brown, 2010; Muller, 2015) had a pre-post design whereas the rest (Cutter, 2014; Dolezal, 2013; Gimnez, 2015;
McDaniel, 2016; Rawson, 2015; Wang, 2017; Zhu, 2016, 2018) featured a control or comparator group, with six (Cutter, 2014; Dolezal, 2013; Rawson,
2015; Wang, 2017; Zhu, 2016, 2018) of them being of a randomized control concept and two a non-randomized one. The
number of participants per study varied between 16 and 200 participants with half of the studies (Brown, 2010; Cutter,
2014; Dolezal, 2013; Gimnez, 2015; Muller, 2015; Rawson, 2015; Wang, 2017) having less than 50 participants. Four (Brown, 2010; Gimnez, 2015; McDaniel,
2016; Muller, 2015) had a sample of mixed dependence (illicit drugs, alcohol, nicotine) participants and six (Cutter, 2014;
Dolezal, 2013; Rawson, 2015; Wang, 2017; Zhu, 2016, 2018) featured participants with only illicit drug dependence (amphetamines,
methamphetamine, methadone).
Exercise intensity varied between light to vigorous, with the majority of the studies using moderate-intensity
exercises. All exercise interventions were supervised, mostly by an exercise professional and all were delivered
in groups, except two
(Cutter, 2014; Dolezal, 2013)
which delivered individually and one
(Muller, 2015)
mixed. All exercise training
sessions were delivered face to face, except one
(Cutter, 2014)
who used a computer game platform.
Eight studies (Brown, 2010; Cutter, 2014; Dolezal, 2013; Gimnez, 2015; Muller, 2015; Rawson, 2015; Zhu, 2016, 2018) used measurements for physical
exercise (e.g., tness tests, attendance), whereas one assessed exercise self-ecacy (Mc Daniel, 2016), and one
craving measures, and Electroencephalographic (EEG) activity (Wang, 2017).
Six studies (Brown, 2010; Cutter, 2014; Gimnez, 2015; Rawson, 2015; Zhu, 2016, 2018) reported a decrease in substance use (or relapses or
cravings) and simultaneously an increase in exercise-related variables (tness or attendance). One study
(Dolezal, 2013)
reported an improvement in tness measures only, one study (Wang, 2017) reported a decrease in substance use
only whereas one study (McDanie, 2016) reported no dierences at all between the 2 groups (exercisers vs. non-
exercisers). Finally, one study (Muller, 2015) reported improvements in physical and psychological health.

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Studies on exercise for SUDs treatment connected to the misuse of illegal drugs
Chapter 3
➤ Behavior Change techniques
All but one (McDaniel, 2016) study, provided a description of how the intervention content was delivered by
the exercise specialists. We coded the interventions’ contents description based on the Behavior Change
Techniques taxonomy (Michie et al., 2013) and the Self-determination motivational behavior change techniques
(Teixeira et al., 2020); the results (list of techniques and frequency of appearance) are set forth on Table 1. The
detailed BCTs per study are displayed in Table 1.
Table 1. List of BCTs and motivational BCTs - frequency of appearance
BCTs Denitions Frequency
1Graded tasks Set easy-to-perform tasks, making them increasingly
dicult, but achievable, until behavior is performed
7
2Self- monitoring
of outcome(s) of
behavior
Establish a method for the person to monitor and record the
outcome(s) of their behavior as part of a behavior change
strategy
7
3Credible source Present verbal or visual communication from a credible
source in favour of or against the behavior
3
4Instruction on
how to perform
the behavior
Advise or agree on how to perform the behavior (includes
‘Skills training’)
3
5Biofeedback Provide feedback about the body (e.g. physiological or
biochemical state) using an external monitoring device as
part of a behavior change strategy
3
6Provide choice Provide opportunities to make choices from a collaboratively-
devised menu of behavioral options and autonomous goals.
It includes the decision not to change, delay change, select
focus/intensity of change, personally endorsed intrinsic goals
and standards for success, including the timing or pace for
certain outcomes.
2
7Social support
(unspecied)
Advise on, arrange or provide social support (e.g. from friends,
relatives, colleagues,’ buddies’ or sta) or noncontingent
praise Or reward for performance of the behavior. It includes
encouragement and counselling, but only when it is directed
at the behavior
2
8Material
incentive
(behavior)
Inform that money, vouchers or other valued objects will be
delivered if and only if there has been eort and/or progress
in performing the behavior (includes ‘Positive reinforcement’)
2
9Material reward
(behavior)
Arrange for the delivery of money, vouchers or other
valued objects if and only if there has been eort and/or
progress in performing the behavior (includes ‘Positive
reinforcement’)
2
➥

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Studies on exercise for SUDs treatment connected to the misuse of illegal drugs
Chapter 3
➤ Descriptives of Literature reviews
There were carried out three systematic reviews (College, 2018; Simonton, 2018; Wang, 2014), one with a
meta-analysis (Wang, 2014), and two (More, 2017; Zschucke, 2012) literature reviews the selection criteria.
Through all reviews, 85 studies have been summarized, all of them targeting illicit drugs either integrally
or in combination with other substances. The three systematic reviews summarized the existing literature
regarding the impact of anaerobic exercise (College, 2018), the eects of long-term physical exercise (Wang,
2014) on SUDs therapy, and exercise preferences and attitudes of people with SUDs in therapy programs
(Simonton, 2018). All types of physical exercise and intensity levels were used in the reviewed interventions.
➤ Synthesized Outcome Findings
Preferences and attitudes towards the physical exercise of people with SUDs
Overall, the results of the reviewed cross-sectional studies indicate that, in a variety of SUDs instances,
individuals are not as physically active as the typical population; still, they express an interest in physical
exercise and sport involvement especially if programs are tailored to their needs.
Identifying barriers and facilitators is also a topic of interest in the reviewed studies. Addicts face issues of poor
physical condition; they might be inexperienced in sports and exercise and oen feel intimidated in physical
exercise environments. An additional nding is that there are signicant dierences in their preferences due
to individual factors (e.g., gender or stage of therapy) regarding exercise-related characteristics, like type,
frequency, and intensity.
Finally, one review (Simonton, 2018) summarized the preferences and attitudes of SUDs people under therapy in
ve respective studies. They reported the most frequently preferred types of exercise to be walking, strength
training, and cycling, activities in which they would like to engage either alone or with small groups, and
would prefer their exercise options to be available on the premises of their treatment clinics.
10 Behavioral
practice/
rehearsal
Prompt practice or rehearsal of the performance of the
behavior one or more times in a context or at a time when
the performance may not be necessary, in order to increase
habit and skill
2
11 Goal setting
(outcome)
Set or agree on a goal dened in terms of a positive outcome
of wanted behavior
1
12 Reward
(outcome)
Arrange for the delivery of a reward if and only if there has
been eort and/or progress in achieving the behavioral
outcome (includes ‘Positive reinforcement’)
1
13 Feedback on
behavior
Monitor and provide informative or evaluative feedback on
performance of the behavior (e.g. form, frequency, duration,
intensity)
1
14 Prompts/cues Introduce or dene environmental or social stimulus with the
purpose of prompting or cueing the behavior. The prompt or
cue would normally occur at the time or place of performance
1
15 Information
about health
consequences
Provide information (e.g. written, verbal, visual) about health
consequences of performing the behavior
1

15
Studies on exercise for SUDs treatment connected to the misuse of illegal drugs
Chapter 3
➤ Outcomes of physical exercise interventions and reviews
Overall, according to the reviewed studies, people with illicit SUDs under therapy who managed to increase
exercise-related variables (tness or attendance) reported that exercise contributed to a reduced desire to
use substances, a reduction in cravings, and increased abstinence. Physical exercise interventions also had
positive psychological outcomes for participants. The reduction of stress, tension, anxiety, and depression
symptoms (Gimnez, 2015; Zhu, 2018), for example, is a common outcome for all exercisers. Individuals in therapy
for illicit drug addiction face intense and prolonged stress, in comparison with other addictions. Therefore,
they experience more positive eects than people with addictions to nicotine or alcohol (Wang, 2014). Additional
positive psychological outcomes reported were optimism in life, life satisfaction, (Cutter, 2014), quality of life, such
as physical function, mental health, vitality, social function, and general health perception (Gimnez, 2015), forgetting
about everyday problems and improved mood as well as improved self-concept and locus of control
(Zschucke, 2012)
.
Physical exercise and/or sport involvement had also positive outcomes on employment, and dwelling (Gimnez, 2015),
as well as physical benets, like decreased injuries and muscle pain, decreased weight, and increased vitality
with improvement in activities of daily living and sleep quality (Zhu, 2018).

16
Studies on exercise for SUDs treatment connected to the misuse of illegal drugs
Chapter 4 Discussion
To overview the available literature regarding sports and physical exercise in relation to illicit drug addiction
treatment, we summarized results of interventions, cross-sectional, and literature review studies to inform
the aim of the Reintegration Through Sport Plus (RTS+) project (www.rtsport.eu).
➤ Available research regarding physical exercise for individuals under SUDs treatment
Overall, the published research in the area of physical exercise for people under treatment for SUDs with
the misuse of illegal drugs is small in quantity and low to moderate in quality. Nevertheless, in the latest
years, there is a trend showing interest in this area of research, and some studies in the last decade comply
with higher standards in research design and methodology. This is also reected in the number of recently
published reviews, which summarize the growing number of research publications. Nevertheless, because of
the still small number of existing studies and with the heterogeneity thereof, reviews may not feed in meta-
analyses. Finally, very few intervention studies used criteria for a BCT, some were of a quasi-experimental
design, whereas other studies suered several methodological limitations.
There are reasonable justications to explain such a lack of research in this area. There are several diculties:
for example, in any longitudinal study design, like behavioral interventions, having recruiting volunteers to
participate is a challenge, since most illicit drug users may just as well not cross paths with the healthcare
system for their addiction. Therefore, recruitment for trials is done via advertisements placed at treatment
centers where patients of illicit drugs receive therapy. Another issue amongst people with illicit substance
use disorders is that they are stigmatized, and consequently afraid of further social or legal consequences of
their addiction, which discourages potential volunteers from signing up to participate in research. Moreover,
people with addiction oen do not wish to engage in treatment or believe they need no treatment at all. Finally,
as many people with addictions are unemployed, poor, or homeless (possibly because of their addiction), they
may lack the resources needed for attending exercise programs. As a result, the attrition rate (discontinuation
of participation) in studies is more than 50%, which ultimately undermines the representability of the results.
➤ Outcomes of physical exercise
Physical exercise in combination with other types of therapy may eectively attenuate withdrawal and
abstinence symptoms for illicit drug addictions. Further, the multitude of benets of exercise on individuals
under SUDs treatment helps them stay motivated towards recovery. As the changes in their body and
psychosocial condition set in, progress helps them to form a new healthier identity whilst the increased
condence may transfer to their eort to stay o their addiction (Cutter, 2014).
Most of the studies that identied psychological positive benets reported positive changes in mood regulation
(stress, depression) and aspects relevant to the quality of life. One of the mechanisms likely to underlay the

17
Studies on exercise for SUDs treatment connected to the misuse of illegal drugs
Chapter 4
stress-relieving eects of exercise could be the stimulation, through exercise, of the production of the brain’s
feel-good neurotransmitters, called endorphins (Goldfarb, 1997).
A number of quality-of-life relevant aspects have also been identied in the reviewed studies to have been
positively aected as a result of engaging in physical exercise (e.g., increased vitality and function). Similar
eects on life quality have been found with respect to Yoga programs for women undergoing detoxication
for heroin dependence (Zhuang, 2013). The latest review from Giménez-Meseguer (2020) also postulates that
physical exercise - both body-mind and physical tness programs - can be eective in improving the quality
of life in SUDs patients.
➤ Designing physical exercise interventions for SUDs treatment connected to the misuse of
illegal drugs
According to cross-sectional studies’ results, tailoring physical exercise interventions to the unique needs and
preferences of the SUDs people under treatment is a crucial element (Abrantes, 2011; Linke, 2015). Tailoring interventions
to the needs of the target group is a key strategy for a successful exercise intervention (Michie et al., 2014).
Exploration of the SUDs population’s preferences and attitudes regarding exercise may lead to more
ecacious exercise interventions with improved adherence and attrition rates and therefore lead to improved
recovery outcomes. Moreover, identication of barriers and facilitators of the specic group helps exercise
program designers to better tailor physical exercise programs and enhance motivation and adherence. The
provision of PE opportunities needs to be exible and regular enough to allow the continued engagement
of participants (Horrell et al., 2020). There is also some evidence that the person-centered approach might
be eective, because of participants’ varying tness levels and underlying medical conditions (Horrell et al.,
2020). Finally, the type of drug, as well as the type of therapy (e.g., with or without replacement) may play a
signicant role in the physical exercise program design.
➤ Behavior change and motivational techniques used at the intervention groups of eective
studies
The most frequent behavior change techniques used in the reviewed intervention studies were the “graded
tasks“ and “self-monitoring“ by the participants, of their physical exercise behavior. This indicates that for drug
addicts to progress slowly with exercise duration and intensity is a very important technique. In so doing, they
are bound to build their condence up step-by-step, especially if they are inexperienced and express concerns
regarding their ability to exercise. Similarly, by “self-monitoring their physical exercise behavior“, they may
actually become conscious of their progress, which in turn boosts their self-esteem towards continuing the
eort. The BCT’s of “credible source“ and “instruction on how to perform the exercise behavior“ heralds the need
to have as an instructor a specialist who is not only knowledgeable of the specic physical exercise or sport but
also a person they value and trust. Finally, “providing choices“ and “social support“ to participants implies that
they need to feel autonomous and supported by their group members while participating in physical activities
(Horrell et al., 2020). Access to physical exercise programs and aordability may also play an important role
in SUDs patients in therapy, especially when they face stigma or poverty. For that reason, using techniques as
“material rewards“ and “incentives“ may also help them to be able to attend physical exercise programs.
➤ Physical exercise characteristics
Most of the reviewed studies provided information regarding the type, intensity, frequency, duration, structure,
and delivery modes. Regarding the type of exercise, studies delved into a wide array thereof, ranging from
aerobic exercise to body and mind types of exercise, with various outcomes. Preferences of participants play
a signicant role in deciding what types of physical exercise we should include in programs for drug-addicts.
Therefore, an assessment of needs with respect to preferences, as well as to barriers and facilitators is a

18
Studies on exercise for SUDs treatment connected to the misuse of illegal drugs
Chapter 4
sine-qua-non process for physical exercise program designers. Moreover, an exercise program should be
preceded by a medical check due to the varying health conditions of participants.
Physical exercise intensity varied along a continuum from light to moderate to vigorous. According to some
researchers, vigorous exercise is not recommended for substance use populations, therefore, moderate-
intensity exercise is preferred for reasons such as the risk of injury or other adverse eects (Simonton, 2018).
Moreover, moderate-intensity exercise has greater adherence rates in comparison to vigorous-intensity
exercise (Heinrich et al., 2014). According to (Nani et al., 2017) exercise intensity did not predict happiness
with life for attendants of rehabilitation centers in Greece, but frequency did. However, intensity should also
be matched to participants’ perceptions of what is achievable.
The majority of the studies considered used group-based delivery of exercise sessions. It seems that addicts
under therapy prefer to engage in physical activities in small groups or a “buddy” system suggesting that they
need social interaction and support when they exercise. Nevertheless, individual preferences should be taken
into account, because exercising alone might also be a preference or a necessity for some.
Regarding the type of delivery, the majority of studies were based on delivery through the physical presence of
an exercise trainer or counselor, except for one study based on virtual delivery. The importance and need for
the presence of a trained physical exercise instructor has been discussed earlier. In addition to the previously
mentioned reasons, a trained exercise specialist is in a position to make decisions regarding how much
supervision the participants need, and based on that to provide feedback and encouragement in order to support
retention and adherence to physical exercise programs. The support, encouragement, and guidance provided
by sta are generally highly valued across a number of study ndings (Linke et al., 2019). Finally, technology-
supported exercise needs further intervention studies to give evidence about the adequacy on this population.
➤ Limitations
Studies currently reviewed in the eld of SUDs treatment with the misuse of illegal drugs provide some
useful initial information allowing us to develop physical exercise training programs that can be used by
professionals of drug treatment organizations and sports organizations. Moreover, they provide some
evidence as to positive treatment eects likely to be achieved using PE interventions as an add-in, under SUDs
treatment schemes. Regarding the identied most eective behavior change techniques, results should be
treated with caution, as in several cases the description of the intervention has not been suciently detailed.
Therefore, there is a possibility that exercise programs used more techniques than they described. This is
a common problem when intervention studies do not use the BCT taxonomy to report their intervention
contents. Moreover, as a result of the application of our inclusion criteria, certain studies may have been le
out that could have provided us with additional information. Systematic reviews and meta-analyses have
already started to become available in the literature, although featuring questions of a more limited scope
than the ones we needed and which we ultimately decided to use. Therefore, readers need to further explore
literature if they need more specic answers to questions regarding the eects of exercise as an adjunct to
therapies for SUDs. Nevertheless, during our study, it became obvious that evidence concerning physical
exercise for illicit drug users under therapy is rather scarce.
➤ Conclusion
Following a review of the literature regarding sports and physical exercise programs as an adjunct to therapy of
illicit drug addiction treatment, we presented initial useful information about designing physical activity programs
for the needs of the Reintegration Through Sport Plus /RTS+ project. However, several gaps in our knowledge
remain and we need more specic and valid information regarding exercise as an adjunct intervention
for SUDs. What is denitely and most specically required are future studies investigating and testing the
potential of mechanisms of interaction between exercise and positive outcomes for SUDs population.

19
Studies on exercise for SUDs treatment connected to the misuse of illegal drugs
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Appendix 1. Data extracted from cross-sectional studies
No of
study
1st author/
year Aim
N of
partici-
pants
Type of Drug(s) Type of
Exercise(s) Relevant Measures/Assessments Results/Outcomes
1Abrantes/
2011
1. to investigate the extent to which substance
dependent patients are interested in engaging
in an exercise intervention as an adjunct to their
substance abuse treatment. 2. to examine patients'
preferences regarding the type, intensity, and timing
of exercise interventions in relation to their ongoing
substance abuse treatment. 3. to determine if there
exist differences in exercise preferences across
substance abuse treatment type (i.e., alcohol
dependence only or drug dependence with or
without alcohol dependence) and by gender.
N=97ς 47.4% alcohol
dependence
only, 52.6%
primary drug
dependence
only or with
concomitant
alcohol
problems
Participants
were queried
on whether they
regularly engage
in an exercise
program of
moderate intensity
activity for at least
20 uninterrupted
minutes.
Motives for Physical Activity Measure,
Barriers to physical activity.
The vast majority (95%) expressed an interest in engaging in an exercise program
specifically designed for persons in substance use recovery and 89% reported
wanting to initiate an exercise program within the first 3 months of sobriety. Specific
exercise preferences regarding type of physical activity, exercise intervention
components, and perceived benefits and barriers to exercise differed between
males and females. These findings suggest low rates of regular exercise, high level
of interest in engaging in exercise during early recovery, and point toward the need
to tailor interventions to the unique preferences of individuals.
2Caviness/
2013
To provide a comprehensive examination of
exercise attitudes and physical activity in a sample
of
MMT smokers (benefits and barriers to exercise).
N=305 Methadone-
maintained
smokers
Physical activity
guidelines -
Any type
International Physical Activity
Questionnaire, Perceived barriers to
exercise, Benefits to exercise (Motives
for Physical Activity Measure), Body-
mass index (BMI).
Nearly 45% endorsed fair or poor physical health. Although participants perceived
many benefits of exercise and few barriers, only 38% of participants met weekly
recommendations for physical activity, and nearly 25% reported no physical activity.
Those who met recommended guidelines were significantly more likely to endorse
relapse prevention as a benefit of exercise. Motivating MMT patients to increase
physical activity could have important physical, mental health, and drug treatment
benefits.
3Linke/
2015
Formative research: To evaluate the following
information among veterans in treatment for
SUDs: (1) interest in an adjunctive exercise
program to supplement their current SUD
treatment; and (2) exercise program design
considerations.
N= 19 Alcohol (50%),
Cocaine (18%).
Physical activity
guidelines - Any
type
“Health Behavior Survey” (past and
current exercise habits and exercise
preferences), Small group interviews
(exercise preferences of veterans in
recovery, with the goal of designing an
exercise program that would maximize
adherence).
A survey and small group interviews were conducted to obtain both quantitative
and qualitative data. Results suggested that veterans with SUDs are interested
in exercise, and participants provided perceptive suggestions for modifying an
existing evidence-based program. These findings used to design an exercise-based
treatment program tailored specifically for veterans with SUDs.
4Nani/2017 To explore the influence of physical activity on the
degree of happiness among drug abusers
N=73 69% opioids,
21% cannabis,
5% cocaine
Any type Godin Leisure-Time Exercise Question-
naire, Happiness with life (Oxford Happi-
ness Questionnaire)
For the dimension of the happiness with life, the results showed that the respond-
ents were only moderately happy. They also moderately exercise in terms of inten-
sity and frequency. Regression analysis indicated that the exercise intensity did not
predict the respondents’ happiness with life. On the contrary, frequency of exercise
predicted the respondents’ happiness. Results suggest that attendants of rehabilita-
tion centers in Greece should be motivated to participate more frequently in exer-
cise and recreation programs to somehow improve their happiness with their life.
5Wang
2019
To determine the critical role of internal inhibition
in the path of physical exertion affecting the drug
cravings of women drug users
N=465 Mixed drugs Any type Physical Activity Rating Scale (PARS-3),
internal Inhibition Scale, Drug Craving
Scale.
Women with traditional drug users had the strongest internal inhibition and new drug
use disorder had the highest drug craving. The longer the duration of drug abuse, the
lower the internal inhibition and the higher the drug craving. Women with moderate-
intensity activity had the strongest internal inhibition and the lowest drug craving.
The physical activity intensity was negatively correlated with drug craving, positively
correlated with intrinsic inhibition, and negatively correlated with drug craving.
Internal inhibition played a partial mediating effect between physical activity intensity
and drug craving.

Appendix 2. Data extracted from intervention studies
No of
study
1st
author/
year
Design Aim N of par-
ticipants Type of Drug(s) Type of Exercise(s) Measures/Assessments BCT coding Results/Outcomes
Type of
delivery
exercise
Who deli-
vered the
Exercise/
Sport
Individual
or Group
sessions
Setting
1Brown/
2010
Pre-post Τo examine the
feasibility of
aerobic exercise
as an adjunct to
substance abuse
treatment among
drug dependent
patients.
N=16 (81,3%) Alcohol,
(31.3%) cocaine,
(31.3%)
marijuana,
(12.5%) opiates,
(6.3%) reported
sedative use
12-week, moderate-
intensity aerobic
exercise intervention
1. Physical activity screen, 2. Structured clinical
interview for DSM-IV (SCID-P; First, Spitzer,
Gibbon, & Williams, 1995). 3.The TLFB interview
(Sobell et al., 1980) was utilized to assess
alcohol and drug use at baseline and during
the follow-up intervals. 4. Cardiorespiratory
fitness was assessed using a submaximal
graded exercise protocol on a motorized
treadmill at baseline and follow-up evaluations.
5. ACSM’s Guidelines for Exercise Testing.
6. 20-item Intervention feedback questionnaire.
8.1 Behavio-
ral practice/
rehearsal,
8.7 Graded
tasks, 2.6
Biofeedback,
2.4 Self-
monitoring of
outcome(s)
of behavior,
9.1 Cred-
ible source,
10.1. Mate-
rial incentive
(behavior),
10.2. Mate-
rial Reward
(behavior).
Participants demon-
strated a signicant
increase in percent
days abstinent for
both alcohol and
drugs at the end
of treatment, and
those who attended
at least 75% of the
exercise sessions
had signicantly
better substance
use outcomes than
those who did not. In
addition, participants
showed a signicant
increase in their
cardiorespiratory
tness by the end of
treatment.
Face
to face
Exercise
specialist
Group Reha-
bilita-
tion
2Cutter/
2014
Rand-
omized
control
trial
To investigate
the feasibility
and acceptability
of an exercise
intervention
comprising the Wii
Fit Plus™ and of a
time-and-attention
sedentary control
comprising Wii™
videogames. We
also explored their
impact on physical
activity levels,
substance use,
and psychological
wellness.
N=29:
Active
Game play
(N=15) or
Sedentary
Game Play
(N=14)
Methadone-
maintained
patients
Active Game Play
(Wii Fit Plus™
videogames
involving physical
exertion) or
Sedentary Game
Play (Wii™
videogames played
while sitting)
1. Acceptability: Satisfaction with the interven-
tion, perceptions of enjoyment, usefulness,
accomplishment, and motivation to continue.
2. Physical Activity In-session activity: Kilo-
calories (kcal), standardized units of energy
expenditure. Exercise intensity was expressed
as “METs, kcals for intermittent time spent
standing between exercises in Active Game
Play as well as for sitting and gaming in
Sedentary Game Play sessions, Height and
Weight. Extra-session activity: Levels of overall
moderate-to-vigorous physical activity (MVPA)
outside of the Wii sessions were measured
weekly with the International Physical Activity
Questionnaire-Long Version (IPAQ-L) in ve
domains: work, transportation, house work,
recreation, and time spent sitting. 3. Substance
Use: The Weekly Substance Use Inventory;
Time Line Follow Back, detailed day-by-day
self-report of drug use. 4. Psychological Well-
ness Outcomes: Perceived stress Perceived
Stress Scale (PSS), Optimism - Life Orientation
Test-Revised (LOT-R), Psychiatric symptomol-
ogy Brief Symptom Inventory-18 (BSI-18),
Life satisfaction, Brief Life Satisfaction Scale
(BLSS).
MBCT
6. Provide
choice.
Participants had
high satisfaction and
study completion
rates. Active Game
Play participants
reported greater
physical activity
outside the
intervention than
Sedentary Game
Play participants
despite no such
differences at
baseline. Substance
use decreased and
stress and optimism
improved in both
conditions.
Mediated Exercise
specialist
Individual
Reha-
bilita-
tion

No of
study
1st
author/
year
Design Aim N of par-
ticipants Type of Drug(s) Type of Exercise(s) Measures/Assessments BCT coding Results/Outcomes
Type of
delivery
exercise
Who deli-
vered the
Exercise/
Sport
Individual
or Group
sessions
Setting
3Dolezal
2013
Rand-
omized
control
trial
To assess the
feasibility and
efficacy of an
8-week endurance
and resistance
training program on
fitness measures
in individuals
undergoing
residential
treatment for
methamphetamine
(MA) dependence.
N=29,
Exercise
training
(ET, N=15)
or Health
Education
without
training
(EA, N=14)
Methampheta-
mine-Depend-
ence
Endurance and
resistance exercise
routines
VO2max, LP strength, and
CP strength, body weight,
body fat, fat weight, Physical
activity 7-day recall
10.10 Reward
(outcome),
2.3. Self-
monitoring
of behaviour,
8.7. Graded
tasks, 4.1.
Instruction
on how to
perform the
behavior, 2.2.
Feedback on
behaviour,
Individuals recovering from metham-
phetamine dependence showed sub-
stantial improvements in aerobic ex-
ercise performance, muscle strength
and endurance, and body composition
with exercise training. The ET group
signicantly improved V O2max, LP
strength, and CP strength and showed
signicant reductions in body weight,
% body fat and fat weight. All changes
were signicant (P<0.001) for ET, and
no changes were seen for the EA
group. These ndings demonstrate the
feasibility of an exercise training inter-
vention in these participants and also
show excellent responsiveness to the
exercise stimulus resulting in physi-
ological changes that might enhance
recovery from drug dependency.
Face
to face
Exercise
specialist
Individual
Reha-
bilita-
tion
4
Gimnez/
2015
Non-Ran-
domized
control
trial
To evaluate quality-
of-life changes in
drug-dependent
patients after
participation in
a group-based
exercise program.
N=37:
Group
exercise
program
(n = 18) -
Routine
care (n =
19)
DSM-IV criteria
for drug
dependence
3 days/week for
60–90 minutes
per session/
over 12 weeks/
aerobic capacity
and muscular
endurance/
moderate to
vigorous intensity
The Six-Minute Walk Test
(6MWT) - submaximal test
measuring aerobic tness,
TGUG - agility and dynamic
balance, Chair Stand Test
(CST) - lower limb strength,
Short Form Health Survey
(SF-36) - quality-of-life.
Qualitative Assessment:
Interviews took place in the
rehabilitation center, lasted
up to 45 minutes, and were
conducted by the same re-
searcher the week aer the
end of the exercise program.
9.1 Cred-
ible source,
3.1 Social
support (un-
specied), 8.7
Graded tasks,
2.4 Self-
monitoring of
outcome(s)
of behavior
Quantitative results showed
improvements in tness and dierent
aspects of quality of life, such as
physical function, mental health,
vitality, social function, and general
health perception. Qualitative results
showed specic physical benets
(decreased injuries and muscle pain,
decreased weight, and increased
vitality with improvement in activities
of daily living), psychological benets
(forgetting about everyday problems,
improved mood, decreased stress
and anxiety), social benets, and a
reduction in craving. The results of
this study provide insight into the
importance of exercise for the quality
of life and recovery process of drug-
dependent patients.
Face
to face
Exercise
specialist
Group Reha-
bilita-
tion
5Mc
Daniel/
2016
Non-Ran-
domized
control
trial
To assess yoga
as a moderator
of substance
abuse treatment
eectiveness, as
indicated by the
Exercise Self-
Ecacy survey
and Treatment
Eectiveness
Assessment
scores.
N=200:
Yoga group
(N=100)
or Non
Yoga group
(N=100).
SUD disorder
Yoga / moderate
intensity
Exercise Self-Ecacy
(ESE) survey, Treatment
Eectiveness Assessment,
and adjunct yoga exercise
was both an independent
and moderating variable.
No
description
The results demonstrated no
signicant dierence with respect to
treatment eectiveness for either the
yoga or non yoga treatment groups.
This study contributes to positive social
change by showing that yoga exercise
is not, contrary to earlier suggestions,
eective at reducing substance
addiction severity.
Face
to face
Exercise
specialist
Group Reha-
bilita-
tion

No of
study
1st
author/
year
Design Aim N of par-
ticipants Type of Drug(s) Type of Exercise(s) Measures/Assessments BCT coding Results/Outcomes
Type of
delivery
exercise
Who deli-
vered the
Exercise/
Sport
Individual
or Group
sessions
Setting
6Muller/
2015
Pre-post To measure
changes in Quality
of Life aer group
exercise among
residential
substance use
disorder patients
and to explore the
feasibility of the
program within a
treatment setting.
N=35
(24 com-
pleters)
Benzodiaz-
epines (41%),
alcohol (38%),
cannabis (28%),
heroin/opiates
(25%),
amphetamines
(25%)
Not a specic type /
30 minutes /
low intensity /
10-week group
exercise program
Quality of Life Brief
(WHOQOL-BREF), Hopkins
Symptoms Checklist
(HSCL-25) - emotional
distress (anxiety and
depression), European
Addiction Severity Index,
Somatic health burden
- amount of somatic
conditions, Program
feasibility was explored
through the attendance data,
spontaneous participant
feedback during the
program, and participants’
answers to open-ended
questions at the end about
program acceptability.
MBCT 6.
Provide
choice, 5.1.
Information
about health
conse-
quences, 7.1
Prompts/
cues, 3.1 So-
cial support
(unspecied),
10.1 Mate-
rial incentive
(behavior),
10.2 Mate-
rial reward
(behavior)
The program was feasible for
participants and the completion rate
was 69%. Completers’ physical health
domain and psychological health
domain of QoL improved signicantly.
The program engaged the most
physically and mentally vulnerable
participants, and exibility and
motivational factors were important
elements. This study provided
promising evidence that low doses of
group exercise can yield appreciable
benets, even to patients with more
severe health problems.
Face
to face
Exercise
specialist
Both Reha-
bilita-
tion
7Raw-
son/
2015
Rand-
omized
control
trial
The primary aim
of this study was
to characterize
the eects of an
8-week exercise
intervention on
Methamphetamine
use outcomes at 1-,
3-, and 6-months
post-discharge
from residential
treatment,
compared to a
health education
control group.
N=135:
Exercise
Group
(N=69)
or Health
education
control
(N=66)
Metham-
phetamine,
dependence
per DSM-IV
Aerobic / moderate /
3 times a week for
8 weeks. Exercise
sessions consisted
of a 5-min warmup,
30 min of aerobic
activity on a
treadmill, followed
by 15 min of weight
training and a
5-min cool-down/
stretching period.
Primary outcome measures
included MA use as
measured by both urine
drug screens (UDS) and self-
report using the Substance
Use Inventory and maximal
exercise performance test
8.1 Behavio-
ral practice/
rehearsal,
8.7 Graded
tasks, 2.6
Biofeedback,
2.4 Self-
monitoring of
outcome(s)
of behavior,
9.1 Credible
source, 1.3
Goal setting
(outcome)
While fewer exercise participants
returned to methamphetamine
(MA) use compared to education
participants at 1-, 3- and 6-months
post-discharge, dierences were not
statistically signicant. A signicant
interaction for self-reported MA use
and MA urine drug test results by
condition and MA severity was found:
lower severity users in the exercise
group reported using MA signicantly
fewer days at the three post-discharge
timepoints than lower severity users
in the education group. Lower severity
users in the exercise group also had
a lower percentage of positive urine
results at the three timepoints than
lower severity users in the education
group. These relationships were not
present in the comparison of the
higher severity conditions. Participants
who were MA abstinent at the 1-month
post-discharge follow-up reported
signicantly more minutes of exercise
(i.e., 118.97 minutes per week) via the
IPAQ than those who were not MA
abstinent (i.e., 90.8 minutes per week)
using UDS results (p = .03; response
rate for the 1-month interview was
N = 102 [exercise n = 54 and health
education n = 48]). Results support
the value of exercise as a treatment
component for individuals using MA 18
or fewer days/month.
Face
to face
Exercise
specialist
Group Post-
resi-
dential
treat-
ment
care

No of
study
1st
author/
year
Design Aim N of par-
ticipants Type of Drug(s) Type of Exercise(s) Measures/Assessments BCT coding Results/Outcomes
Type of
delivery
exercise
Who deli-
vered the
Exercise/
Sport
Individual
or Group
sessions
Setting
8Wang
2017
Rand-
omized
control
trial
To determine the
eects of aerobic
exercise training
on craving and
inhibition control
among people with
MA dependencies.
N=50:
Aerobic
group
(N=25) or
Attention
Control
group
(N=25)
Methampheta-
mine depend-
ence
Three 30-min
sessions per week
of
moderate intensity
aerobic exercise
(i.e., cycling,
jogging, or jump
rope) for 12 weeks.
Craving measures,
Inhibitory control measures,
neutral and MA-related
inhibitory control, elicited
neuroelectric activation
(Electroencephalographic
(EEG) activity).
8.7 Graded
tasks, 2.6
Biofeedback,
2.4 Self-
monitoring of
outcome(s)
of behavior.
The current study provides the rst
evidence that aerobic exercise training
may be efcacious for MA-associated
cravings and inhibitory control from
behavioral and neuroelectric
perspectives among MA-dependent
individuals.
Face
to face
Exercise
specialist
Group Drug
Reha-
bilita-
tion
Bureau
9Zhu
2018
Rand-
omized
control
trial
To investigate if
Tai-Chi practice
can improve sleep
quality and mood
of females who
are dependent on
amphetamine-type
stimulant (ATS).
N=80: Tai
Chi group
(N=42) or
Standard
Care
(N=38).
Αmphetamine-
type stimulant
(ATS)
Tai Chi (medium
intensity, ve times
a week during the
rst 3 months and
three times a week
during the second 3
months).
Self-rated Pittsburg Sleep
Quality Index (PSQI), Self-
Rating Depression Scale
(SDS), tness aer 3 and 6
months.
8.7 Graded
tasks, 4.1.
Instruction
on how to
perform the
behavior.
Result suggested that TaiChi (TC)
had positive eects on sleep quality,
depression and tness. Long-term
study demonstrated that TC may be
a cheap and potential supplementary
treatment for ATS-dependent
individuals. TC may also be considered
as an alternative exercise to escalate
abstinence for ATS-dependent females.
Face
to face
Exercise
specialist
Group Reha-
bilita-
tion
center
10 Zhu
2016
Rand-
omized
control
trial
To assess the
quality of life and
physical eects of a
Tai Chi intervention
on individuals with
amphetamine-
type stimulant
(stimulant)
dependence.
N=59: Tai
Chi group
(N=30) or
Standard
Care
(N=29).
Αmphetamine-
type stimulant
(ATS)
Tai Chi (medium
intensity, ve times
a week for 12
weeks).
Quality of life scale for drug
addiction (QOL-DAv2.0),
Fitness test
8.7 Graded
tasks, 4.1.
Instruction
on how to
behavior.
Test scores of the QOL-DA in the
Tai Chi group significantly increased
after 12 weeks in the following areas:
physiology, symptoms, society, and
QoL total score. A post hoc test further
revealed that quality of life improved
in the Tai Chi group but not in the
standard care group. Physical results
showed a significant interaction with
balance and participants in the Tai
Chi group improved by 10 s while
there was no change in the standard
care group. Although there were no
significant interactions in the fitness
outcomes (i.e., hand-grip and sit-and-
reach tests), the within-group factor
displayed significant changes in body
fat (F(1,56) = 27.79, p < 0.001) in both
groups.
Face
to face
Exercise
specialist
Group Reha-
bilita-
tion
center

Appendix 3. Data extracted from review studies
No of
study
1st
author/
year
Review
type Aim
Number
of included
studies
Geographic
areas Inclusion criteria Type of Drug(s) Type of
Exercise(s) Results/Outcomes
1Colledge/
2018
Systematic
Review
To document the implemen-
tation of anaerobic exercise
in the treatment of SUDs.
26
University
of Con-
necticut
Health
Center,
Farming-
ton,
CT
Included in the review are all studies
which, as a form of treatment for
SUDs, involved acute or chronic
exercise of the following type:
(1) reported by authors as being at
or above the specifically determined
IAT; (2) at or above a heart rate
which corresponds to 75% of
maximum, (3) at or above 70% of
heart rate reserve, (4) at a score
of 14 or above on the Borg scale,
(5) described by the authors as
vigorous, intense, or anaerobic, or
(6) involving activities which may
incorporate bouts above the IAT,
where the authors do not explicitly
state that this was not the case, by
reporting physiological data (for
example, heart rate below 75% of
maximum). These activities are
defined as any type of sport, exercise
or structured physical activity
excluding yoga, Pilates, stretching,
walking, medical rehabilitation, Qi
Gong, or Tai Chi.
Cigarettes (12 studies),
alcohol (1 study), and all
illicit and prescription
drugs (13 studies)
Anaerobic
exercise training
The findings of this review suggest that anaerobic or vigorous
exercise may have a positive effect on a number of outcomes in
populations with a SUD. The most positive effects being found
for abstinence in nicotine dependence. The effects of anaerobic
exercise cannot be determined, and therefore not evaluated or
compared with other forms of exercise. “Further studies are required
to establish the optimum intensity of exercise intervention required.
2More/
2017
Litearture
Review
1. To identify factors associ-
ated with the development
and
persistence of substance
use disorders among youth.
2. To
identify current treatment
modalities, and
present evi-
dence to support the ecacy
of incorporating exercise
participation
during rehabili-
tation. 3. To provide a series of
recommendations
for future
research that explores the
feasibility and eectiveness
of exercise participation as
a complement to substance
use disorder treatment
among youth.
Unspecied Young
person as
‘at-risk’
within
Western
societies
Not applicable SUD disorders
according to DSM
Exercise participa-
tion in general
- Any type
1. ‘At-Risk’ Populations, Parents and family, School, Peers,
Stress, Boredom, Mental health. 2. No consistent and universally
accepted therapy approach exists, the primary goal of many
SUD rehabilitation programs is abstinence, attained through the
treatment of the physiological, psychological, and sociological
problems presented by the individual. More holistic goals,
including harm minimization, facilitating access to education,
reducing substance use, improving interpersonal relationships,
and improving physical and mental health, may also be targeted.
3. Very little research exists in the area of exercise on SUD, and as
a result, the feasibility and/or outcomes of exercise participation
within youth SUD populations are relatively unknown.
RECOMMENDATIONS FOR FUTURE RESEARCH: 1. : Examine
Exercise Perceptions and Attitudes among Youth with SUDs;
2. Examine Recovery-Related Outcomes Associated with Exercise
Participation; 3. : Identify Community Transition Pathways and
Long-Term Outcomes.

No of
study
1st
author/
year
Review
type Aim
Number
of included
studies
Geographic
areas Inclusion criteria Type of Drug(s) Type of
Exercise(s) Results/Outcomes
3
Simonton/
2018
Systematic
Review
To explore previous research
regarding PA/exercise
preferences for those with
SUDs. Research questions:
1. What research is currently
available regarding PA/
exercise preferences in
those with a SUD? 2. What
were the designs (location,
SUD population, data collec-
tion methods, etc.) of these
studies? 3. What were the
preferences and/or attitudes
of those with SUDs regarding
PA/exercise?
5 United
States
1. Written in English, 2. peer
reviewed, 3. pertaining to a popula-
tion with a SUD, 4. preferences or
attitudes as a primary outcome.
SUD Any type The ndings of this review, though limited, nonetheless suggest
that people with SUDs are interested in increasing their PA.
Facilitators/Benets: PA would provide a sense of accomplishment
and condence, would improve physical health, and could increase
one’s condence to stay sober. Barriers: lack of motivation, nancial
restrictions, disability or injury and lack of energy. Social environment:
Preferred engaging in PA alone or with a small group or a buddy
system, indicating that foster support and encouragement for PA
should be a part of an intervention. Types of preferred exercise:
interested in discussing exercise (women more than men), incor-
porating strength/resistance training, activity tracks (pedometer),
Walking, Gym, bicycling, Sports, Yoga, Recreational activities,
Competitive without friction, Exercise counseling during treatment.
Structure: Face-to-face from an exercise counselor, Scheduled,
Combined supervised / unsupervised or supervised, with a Men-
tor, Unsupervised, self-paced, or Do it yourself with professional
guidance. Intensity: Moderate, Light, Multiple, ranging from easy to
dicult. Emphasized it can’t be too strenuous or intense
4Wang/
2014
Systematic
Review
with
Meta-
analysis
To examine whether long-
term physical exercise
could be a potential eective
treatment for substance use
disorders (SUDs).
22 Raju,
Georgia
Regents
University,
United
States of
America
1. The selected papers were
studying physical exercise
intervention’s eect on drug abuse,
excluding preventive studies.
2. All research use RCT. 3. Objects of
the study were adults over 18 years
old who were assessed as alcohol,
nicotine, and illicit drug abusers
through the DSM-III(R)/IV.
Alcohol (3 studies),
nicotine (11 studies),
illicit drug abusers
(5 papers), and polydrug
abusers of alcohol,
nicotine, and illicit drugs
(4 studies) / DSM-III(R)/
IV
Any type The results indicated that physical exercise can eectively
increase the abstinence rate, ease withdrawal symptoms, and
reduce anxiety and depression. The physical exercise can more
ease the depression symptoms on alcohol and illicit drug abusers
than nicotine abusers, and more improve the abstinence rate on
illicit drug abusers than the others. Similar treatment eects were
found in three categories: exercise intensity, types of exercise, and
follow-up periods. Although physical exercise has been proven ef-
fective in facilitating drug abstinence, its eects on alcohol, nicotine
and illicit drug abusers are dierent. From the results of the meta-
analysis, the eects of physical exercise on illicit drugs abusers
are signicantly greater compared to others. Given the limitation of
materials, these issues require further investigation.
5Zschucke/
2012
Litearture
Review
This paper aims at subsuming
empirical evidence for
therapeutic eects of PA
and EX in SUD and arriving
at conclusions concerning
further research and clinical
practice.
Alcohol
(9 RCTs),
nicotine
(17 RCTs),
and illicit drug
(8 studies)
Not
specic
For nicotine abuse and dependence,
only randomized-controlled trials
(RCTs) were included into this paper.
Since the literature was very limited
concerning RCTs on alcohol abuse/
dependence and illicit drug abuse/
dependence, studies with inad-
equate control strategies and small
samples were also included into this
paper. Studies in English or German
published between 1970 and 2011
which had investigated any form
of EX as therapeutic intervention
strategy. Search terms included “ex-
ercise,” “physical activity,” “substance
use disorder,” “dependence,” “abuse,”
“illicit drugs,” “alcohol,” “nicotine,”
“cannabis,” “opiate,” “stimulant,”
and “cocaine,” in the respective
languages.
Illicit drugs Any type Illicit drugs: Positive outcomes for craving, percentage of abstinent
subjects, continuous days of abstinence. Secondary psychological
and social outcomes like depression, anxiety, tension, self-concept,
locus of control, employment, and dwelling were increased at least
in one of the exercise conditions. Fitness increased in 3 studies. /
Alcohol: Signicant improvements on drinking episodes, craving,
or days of abstinence as substance-related outcomes. Secondary
psychological outcomes like depression, anxiety, stress, self-
concept, locus of control, and sleep quality, which increased at least
in one of the EX conditions. / Nicotine: Evidence is mixed, but some
preliminary conclusions can be drawn concerning favorable eects
of EX intervention in smoking cessation. Acute eects of exercise
are favorable for a number of variables. EX adherence rather than
the admission to an EX intervention per se predicted smoking
abstinence, suggesting an important role of motivation, individual re-
sources, and self-ecacy. Exercise interventions showed the clearest
eects when compared to standard treatment, which becomes more
unequivocal, when EX is compared to control groups which oer a
similar amount of social support, therapeutic contact, and preoccu-
pation with health-related topics. The majority of studies have shown
that EX interventions are as eective as other standard interventions
for smoking cessation, such as CBT or NRT/medication.

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Reggio Emilia Onlus