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Mental Health and Physical Activity 3 (2010) 27e34

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Mental Health and Physical Activity

journal homepage: www.elsevier .com/locate/menpa

A pilot study of aerobic exercise as an adjunctive treatmentfor drug dependence

Richard A. Brown a,*, Ana M. Abrantes a, Jennifer P. Read b, Bess H. Marcus c, John Jakicic d,David R. Strong a, Julie R. Oakley e, Susan E. Ramsey f, Christopher W. Kahler g,Gregory L. Stuart a, Mary Ella Dubreuil h, Alan A. Gordon h

aAlpert Medical School of Brown University/Butler Hospital, USAbUniversity at Buffalo, The State University of New York, USAc Program in Public Health, Brown University, USAdUniversity of Pittsburgh, USAe The Westerly Hospital, Westerly, RI, USAfAlpert Medical School of Brown University/Rhode Island Hospital, USAgCenter for Alcohol and Addiction Studies, Brown University, USAhButler Hospital, USA

a r t i c l e i n f o

Article history:Received 13 November 2009Received in revised form4 March 2010Accepted 5 March 2010

Keywords:ExercisePhysical activityAerobicDrug dependenceDrug treatmentInterventionSubstance abuse treatmentPhysical activity

* Corresponding author at: Alpert Medical SchooHospital, 345 Blackstone Blvd., Providence, RI 02906,fax: þ1 401 455 6424.

E-mail address: richard_brown@brown.edu (R.A. B

1755-2966/$ e see front matter � 2010 Elsevier Ltd.doi:10.1016/j.mhpa.2010.03.001

a b s t r a c t

Intervention to increase exercise in drug dependent patients represents a potentially useful yet unex-plored strategy for preventing relapse. However, there are currently no established exercise interven-tions for use with this population. The purpose of this pilot study was to examine the feasibility ofaerobic exercise as an adjunct to substance abuse treatment among drug dependent patients. Partici-pants included 16 (31% female, 38.3 years old) drug dependent patients who participated in a 12-week,moderate-intensity aerobic exercise intervention. Participants attended a mean of 8.6 sessions (outof 12). Participants demonstrated a significant increase in percent days abstinent for both alcohol anddrugs at the end of treatment, and those who attended at least 75% of the exercise sessions hadsignificantly better substance use outcomes than those who did not. In addition, participants showeda significant increase in their cardiorespiratory fitness by the end of treatment. While preliminary, thisstudy is one of the first to demonstrate the feasibility of incorporating aerobic exercise during drug abusetreatment. Future randomized control trials are a necessary next step to test the efficacy of a moderate-intensity aerobic exercise intervention as an adjunct to drug abuse treatment in this patient population.

� 2010 Elsevier Ltd. All rights reserved.

1. Introduction

Drug dependence is a major public health problem (McCrady &Epstein, 1999; Rotgers, Keller, & Morgenstern, 1996) and the asso-ciated costs of drug use disorders to society are considerable(Andlin-Sobocki, 2004; Langenbucker, McCrady, Brick, & Esterly,1993; ONDCP, 2004). Results from the U.S. National EpidemiologicSurvey on Alcohol and Related Conditions (NESARC) point towardhigh rates of substance use disorders (SUD) with 9.5% of the pop-ulation meeting DSM-IV criteria for any SUD and 4.07% meeting

l of Brown University/ButlerUSA. Tel.: þ1 401 455 6254;

rown).

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criteria for any substance dependence within the last 12 months(Grant et al., 2004). Epidemiological data from 27 communitystudies in European countries reveal a 12-month prevalence ratefor any substance dependence of 3.4% of the adult population(Wittchen & Jacobi, 2005). Spontaneous remission rates from drugdiagnoses are very low (Finney, Moos, & Timko, 1999). Relapserepresents a major problem in substance use disorders, withrelapse rates in the first year following treatment ranging from 60to 90% (Brownell, Marlatt, Lichtenstein, & Wilson, 1986; Hunt,Barnett, & Branch, 1971; Xie, McHugo, Fox, & Drake, 2005). There-fore, it is crucial that accessible, affordable and efficacious primaryand adjunctive drug dependence treatments be developed toaddress this chronic, relapsing condition.

The role of increasing lifestyle balance has been incorporatedin existing relapse prevention models (Marlatt & Witkiewitz,2005; Witkiewitz & Marlatt, 2004). Indeed, in his chapter on

R.A. Brown et al. / Mental Health and Physical Activity 3 (2010) 27e3428

“Lifestyle Modification,” Marlatt cites exercise as “a highly rec-ommended lifestyle change activity” (Marlatt, 1985, p. 309) anddiscusses the advantages of physical activity as a relapseprevention strategy. Other writers have agreed that lifestyle-enhancing factors such as exercise and fitness may play animportant role in the prevention and treatment of addictivedisorders (Brown et al., 2009; Tkachuk & Martin, 1999). Larimerand colleagues (Larimer, Palmer, & Marlatt, 1999) describe theimportance of helping the client develop “positive addictions”such as increased physical activity and meditation. Althoughlifestyle modification was one of the main components in Mar-latt’s relapse prevention model [see Marlatt and Donovan (2005)for more details], the treatment outcome literature suggests thatthis component has received the least emphasis in relapseprevention programs for drug dependence. Despite this lack ofattention in the empirical literature, methods that attempt tofoster healthy lifestyle changes may contribute to long-termmaintenance of recovery, and interventions targeting physicalactivity in particular, may be especially valuable as an adjunct tosubstance abuse treatment.

Exercise may benefit drug dependent patients attemptingrecovery from substance problems through a number of differentmechanisms of action. First, engaging in exercise may offer drugdependent patients the ability to experience positive mood stateswithout the use of drugs. For example, due to the potential forreductions in dopamine production and dopamine receptorsavailability, drug dependent patients may have an impairedcapacity to experience pleasure during early recovery (Adinoff,2004; Bressan & Crippa, 2005). On the other hand, exercise hasbeen shown to result in acute improvements in positive-activatedaffect (e.g., Reed & Ones, 2006) and alleviate mood disturbance andwithdrawal symptoms in women attempting to quit smoking (e.g.,Bock, Marcus, King, Borrelli, & Roberts, 1999). These positive rein-forcing properties may be mediated in part by exercise effects onthe endogenous opioid system and potentiation of dopaminergicsystems linked importantly to the experience of enhanced moodand experienced pleasure (cf., (Meeusen, 2005), although theapplication of neuroscience techniques to exercise psychology iscomplex and will require strong research designs (Dishman &O’Connor, 2009). Second, studies in recent years have found anassociation between depressive symptomatology and poor treat-ment outcome among patients with substance use disorders(Brown et al., 1998; Nunes & Levin, 2004; Ouimette, Gima, Moos, &Finney, 1999; Poling, Kosten, & Sofuoglu, 2007). Engaging in exer-cise has been consistently associated with reductions in depressivesymptoms (Craft & Landers, 1998; Dunn, Trivedi, & O’Neal, 2001;Lawlor & Hopker, 2001; Mead et al., 2009) and thus exercise mayreduce risk for relapse by reducing depressive symptoms. Third,exercise has been found to alleviate sleep disturbances(Youngstedt, 2005) and improve cognitive functioning (Kramer &Erickson, 2007) e both of which have been identified as dis-rupted in early drug recovery and predictive of relapse(Drummond, Gillin, Smith, & DeModena, 1998; Ersche & Sahakian,2007; Gruber, Silveri, & Yurgelun-Todd, 2007; Jovanovski, Erb, &Zakzanis, 2005; Liu, Xiaoping, Wei, & Zeng, 2000; Rogers &Robbins, 2001; Scott et al., 2007). Lastly, increases in self-efficacy(McAuley, Courneya, & Lettunich, 1991) and decreases in stress-reactivity (Hobson & Rejeski, 1993; Keller, 1980) associated withexercise engagement may also contribute to lower the risk ofrelapse among drug dependent patients. Among problem drinkers,exercise led to psychological improvement in physical self-worthand physical self-perceptions of condition and strength (Donaghy &Mutrie, 1998). Exercise has been proposed as an effective relapseprevention intervention specifically due to the potential number ofpositive physiological and psychological benefits. Improved mood,

regulated reward systems, reduced depressive symptoms,improved sleep and cognitive function all may serve to reduce riskfor relapse and efforts to illuminate mechanisms of effectivenesswill be an important focus of future work in this area.

Thus far, few studies have examined the efficacy of aerobicexercise as adjunct to substance abuse treatment. Among addictivedisorders, nicotine dependence has received the most attentionwith respect to the role of physical activity. Recent studies havedemonstrated the acute effects of exercise on decreased cravingand nicotine withdrawal (see Taylor, Ussher, & Faulkner, 2007) andas a means of facilitating smoking cessation (Marcus et al., 1999;Marcus et al., 2005; Prapavessis et al., 2007).

The role of exercise as an adjunct to alcohol treatment has beenexplored by Sinyor and colleagues (Sinyor, Brown, Rostant, &Seraganian, 1982) who reported on 58 participants receivinginpatient alcohol rehabilitation treatment. Participants engaged insix weeks of “tailored” exercise, consisting of progressively morerigorous physical exercise including stretching, calisthenics andwalking/running. Results revealed that these participants demon-strated better abstinence outcomes post-treatment than did non-exercising participants from two other small comparison groups. Inaddition, in a previous study, we developed and pilot testeda 12-week moderate-intensity aerobic exercise intervention foralcohol dependent patients (Brown et al., 2009). Results from thisstudy suggest that, compared to the mean pretreatment percentdays abstinent (PDA), significant increases in PDAwere observed atthe end of the 12-week exercise intervention and at the 3-monthpost-intervention follow-up.

Similar to alcohol treatment, there exists a lack of studiesexamining the role of exercise during drug abuse treatment(Donaghy & Ussher, 2005). In one small, uncontrolled pilot study ofan exercise intervention conducted with substance abusingoffenders in outpatient treatment,Williams (2000) conducted a 12-week intervention consisting of once weekly strength traininggroups plus recommendations for aerobic exercise during the restof the week. While substance abuse outcomes were not presentedin the results, the authors reported that the 11 out of 20 participantswho completed the intervention reported that exercise was helpfulin maintaining abstinence. In addition, exercise interventions havebeen applied with adolescent substance abusers. Collingwood andcolleagues (Collingwood, Reynolds, Kohl, Smith, & Sloan, 1991)conducted a clinical trial of an 8e9 week structured fitnessprogram with adolescent substance abusers. Adolescent partici-pants showed improved physical fitness, reduced polysubstanceuse, and increased abstinence rates. Overall, there exists a lack ofavailable studies attempting to evaluate the potential of exercise tobenefit adults in treatment for drug use disorders. Stronger studiesare needed to establish that exercise interventions should be morebroadly implemented in practice.

The purpose of this study was to pilot test a 12-week moderate-intensity aerobic exercise intervention as an adjunct to treatmentfor drug dependent outpatients, as a preliminary step in a programof research. In this study, we examine the feasibility and exerciseadherence among drug dependent patients. In addition, weexamine drug use and cardiorespiratory fitness outcomes at theend of the 12-week intervention and at the 3-month follow-up.

2. Method

2.1. Participants

Participants were recruited from an intensive alcohol and drugtreatment partial-hospitalization program at a psychiatric hospitalin the Northeast USA as well as through study advertisements inthe local newspaper. Eligible participants: (a) were between 18 and

R.A. Brown et al. / Mental Health and Physical Activity 3 (2010) 27e34 29

65 years of age, (b) met current DSM-IV criteria for drug depen-dence as assessed by the Structured Diagnostic Interview for DSM-IV (SCID-P), (c) were sedentary; i.e., have not participated regularlyin aerobic physical exercise (for at least 20 min per day, three daysper week) for the past six months, and (d) were currently engagedin outpatient substance abuse treatment.

Exclusion criteria included: (a) anorexia or bulimia nervosa, (b)bipolar disorder, (c) a history of psychotic disorder or currentpsychotic symptoms, (d) current suicidality or homicidality, (e)marked organic impairment, (f) physical disabilities or medicalproblems or use of medications that would prevent or hinderparticipation in a program of moderate-intensity exercise, and (g)current pregnancy or intent to become pregnant during the next12 weeks.

From the alcohol and drug partial hospital treatment program,208 charts of patients with drug dependence were screened. Inaddition, 108 calls were received in response to newspaper adver-tisements for the research study. Of these 316 potential partici-pants, rule outs included: 58 (18%) for a medical problem thatwould prohibit safely participating in exercise, 35 (11%) were notsedentary, 40 (13%) refused participation in the study (applicableonly to patients from the partial hospital treatment program), 37(12%) for one of the psychiatric exclusion criteria, and 47 (15%) werenot involved in ongoing substance abuse treatment or were ina methadone maintenance program (applicable only to thosecalling in response to the newspaper advertisement). In addition,during the recruitment process, 64 (20%) of potential participantseither expressed loss of interest in the study, dropped out ofaddiction treatment, were unable to attend group nights, or we lostcontact with them.

As a result, the remaining 35 participants were scheduled forbaseline assessments. Of these, 6 were excluded because of a SCID-diagnosed psychiatric rule out and 10 decided to no longerparticipate during the baseline assessment phase. Therefore, 19participants were eligible to participate in the 12-week aerobicexercise intervention. Of these, 3 participants did not attend theintervention and were not able to be contacted further. Thus,the study sample was comprised of 16 participants who initiatedthe exercise intervention.

The sample of 16 participants included 11 (69%) males and 5(31%) females. The mean age of participants was 38.3 (SD ¼ 10.1)years. The sample was primarily Caucasian (13 of 16; 81.3%) withaminority of African-American (13%) and Hispanic (6%) individuals.Participants had an average of 12.5 (SD ¼ 1.4) years of education.Seven participants (43.8%) were married, 6 (37.5%) were nevermarried, and 3 (18.7%) were either divorced or separated. In addi-tion, nine participants (56.2%) were employed full-time, while 4(25%) were working part-time and three (18.6%) were currentlyunemployed. All participants were engaged in ongoing substanceabuse treatment for drug dependence. In the 3 months prior tobeginning the intervention, 81.3% reported using alcohol, 31.3%used cocaine, 31.3% used marijuana, 12.5% used opiates, and 6.3%reported sedative use. In the one month prior to the intervention,63.7% of participants used two or more substances. In our clinicalexperience, it is common for drug dependent patients to also drinkalcohol and to believe they can continue to drink while remainingabstinent from drugs.

Accordingly, while alcohol use was common in the sample, allparticipants were recruited if they met criteria for a current (i.e., inthe last year per DSM-IV) drug dependence diagnosis and wereengaged in substance abuse treatment irrespective of when theaddiction treatment began. Therefore, participants began theexercise intervention with varying degrees of addiction treatmentengagement. However, in the 3 months prior to study recruitment,most participants were engaged in both substance abuse and

mental health treatment. Addiction focused treatment included:inpatient (31%), partial hospital day program (75%), individualsessions with a psychiatrist (37.5%), individual sessions witha counselor (50%), group therapy (25%). In addition, 56% of thesample had attended 12-step meetings in the last 3 months. Mentalhealth treatment included: individual sessions with a psychiatrist(50%) and counselor (31.2%).

In addition, participants continued to engage in concurrentsubstance abuse and mental health treatment during the 12-weekexercise intervention. Addiction focused treatment included:inpatient (7.1%), partial hospital day program (14.3%), individualsessions with a psychiatrist (30.8%), individual sessions witha counselor (60%), group therapy (28.6%). In addition, 71.4% of thesample had attended 12-step meetings during the 3-month inter-vention. Mental health treatment included: partial hospital dayprogram (7%), individual sessions with a psychiatrist (28.6%),individual sessions with a counselor (40%), and group therapy (7%).

2.2. Exercise intervention

There are three components to the exercise intervention:1) moderate-intensity aerobic exercise, 2) group behavioraltraining component, and 3) an incentive system. The exerciseintervention was also tested with a sample of alcohol dependentpatients and has been published elsewhere (Brown et al., 2009).Werefer readers to this publication for detailed descriptions of eachexercise component.

2.2.1. Aerobic exercise component of the exercise interventionParticipants attended supervised (by an exercise physiologist)

aerobic exercise group sessions once a week (for 12 weeks) at thestudy fitness facility. At each exercise intervention session, theexercise physiologist guided participants on the intensity andduration of the exercise to be performed. Exercise sessions began at20 min per session and gradually progressed to 40 min per sessionby week 12. Participants exercised at a rate that achieved 55e69%(moderate-intensity) of age-predicted maximal heart rate. Thisexercise regimen is consistent with the guidelines offered by theAmerican College of Sports Medicine (ACSM; American College ofSports Medicine, 2000). Heart rate and blood pressure weremonitored before, during, and after exercise. Each workout sessionalso included a 5-min warm-up and a 10-min cool-down to ensuresafe exercise procedures. Several types of exercise equipment wereavailable to study participants, including treadmills, recumbentbicycles, and elliptical machines. Participants in the study were alsogiven “prescriptions” from the exercise physiologist (tailored totheir level of fitness) to engage in moderate-intensity aerobicexercise on a minimum of two to three other occasions during theweek for the duration of the 12-week exercise program. Theseother exercise occasions took place outside of the study fitnessfacility (e.g., in their home or through community resources). Inaddition, participants were required to self-monitor their exerciseby filling out a weekly exercise log with the various exerciseactivities they engaged in during the week, the duration of eachactivity, and their self-reported rate of perceived exertion (RPE) foreach activity.

2.2.2. Weekly group behavioral training componentof the exercise intervention

Given the demonstrated efficacy of behavioral modificationstrategies in increasing physical activity (Woodard & Berry, 2001),this weekly, brief (15e20 min) group intervention based on cogni-tive and behavioral techniques was incorporated as a component ofthe exercise intervention. Through these weekly groups, co-led byboth an exercise physiologist and psychologist, participants were

R.A. Brown et al. / Mental Health and Physical Activity 3 (2010) 27e3430

guided as to how to increase overall fitness through behavioralchanges in their daily lives. Each brief group sessionwas focused ona certain topic designed to increase overall motivation resulting inimproved exercise adherence and maintenance.

2.2.3. Incentive component of the exercise interventionIn order to maximize adherence to the exercise program and

self-monitoring of daily exercise activities, participants earnedincentives for various levels of adherence to the exercise program.The incentive plan consisted of providing participants with $5 forattending each weekly combined group/exercise session and anadditional $5 for returning their completed exercise self-moni-toring form (from the prior week) at that session. In addition,participants earned the opportunity to draw a prize from a fishbowl(value ranging from $10-$50) at each weekly session, if they hadconsecutive attendance (i.e., had attended the prior week’sgroup þ exercise session).

2.3. Procedure

2.3.1. RecruitmentParticipants were recruited from two sources. First, the medical

records of all patients entering the intensive alcohol and drugtreatment partial-hospitalization program at a psychiatric hospitalin the Northeast were screened for the psychiatric and medicalinclusion and exclusion criteria detailed above. Second, interestedparticipants responding to study advertisements in the localnewspaper called the study center. In each case, participants wereinitially screened to determine potential eligibility based upon thesedentary criterion. For individuals meeting the sedentary eligi-bility criterion, informed consent for study enrollment wasobtained and potential participants were evaluated using thediagnostic and assessment measures and a medical history reviewand graded exercise test under the supervision of the studyphysician to confirm eligibility.

The study physician reviewed the patient’s medical history. Aresting electrocardiograph (ECG) was then obtained. Unless con-traindicated by the resting ECG, the physician then had the patientcomplete a submaximal graded exercise test on a treadmill, withcontinuous ECGmonitoring using a modified, BalkeeWare protocol(American College of Sports Medicine, 2000) that was terminatedat 85% of the participant’s age-predicted maximal heart rate(see below for a more detailed description of the submaximalgraded treadmill test). The physician reviewed the results of thegraded exercise test and made the final determination regardingstudy eligibility.

2.3.2. Follow-up assessmentsParticipants completed follow-up interviews 3 (end of treat-

ment) and 6 months following recruitment into the study. Toreduce attrition, participants were paid $40 and $50 for completionof the 3- and 6-month follow-up interviews, respectively. Allpayments were made in gift certificates to a local shopping mall orsupermarket.

2.4. Measures

2.4.1. Physical activity screenTo determine whether patients were sedentary, participants

were asked the frequency and duration of at least moderate-intensity exercise (described as the equivalent of a brisk walk) overthe last six months. Participants were considered sedentary if theirresponses suggested they were exercising less than 3 times a weekfor at least 20 min per day over the entire previous six months.

2.4.2. Structured clinical interview for DSM-IV(SCID-P; First, Spitzer, Gibbon, & Williams, 1995)

Psychiatric disorders, both current and lifetime, for establishinginclusion/exclusion criteria were determined by the relevantsections of the SCID-P (First et al., 1995).

2.4.3. Time-line-follow-back (TLFB; Sobell & Sobell, 1996)The TLFB interview (Sobell et al., 1980) was utilized to assess

alcohol and drug use at baseline and during the follow-up intervals.At baseline, it was administered for the 90 days prior to admissionand at each follow-up interval for the period since its last admin-istration. The TLFB interview is a calendar-assisted structuredinterview that provides away to cuememory so that accurate recallis enhanced. A structured interview of patients’ drinking behaviorhas been found to be the most reliable and valid method ofassessing prior alcohol use (Sobell & Sobell, 1979, 1980). In partic-ular, the TLFB interview has excellent reliability (Sobell, Maisto,Sobell, & Cooper, 1979) and validity (Sobell & Sobell, 1980). Datafrom the TLFB were summarized by month to yield the primaryoutcome variables: percent days abstinent (i.e., number of absti-nent days divided by number of days not in a restricted environ-ment) for 1) alcohol and 2) drugs.

2.4.4. Cardiorespiratory fitnessCardiorespiratory fitness was assessed using a submaximal

graded exercise protocol on a motorized treadmill at baseline andfollow-up evaluations. For the graded exercise test, the speed of thetreadmill was constant at 3.5 mph with the initial grade set at 0%and progressed by 1% at 1-min intervals. During testing, heart ratewas assessed eachminute and at the point of test termination usinga 12-lead electrocardiogram. Blood pressure was measured at 2-min intervals during the test. Further, ratings of perceived exertion(Borg 6e20 scale) were obtained at 1-min intervals during the test(Borg, 1998). This submaximal exercise test was terminated at 85%of the participant’s age-predicted maximal heart rate (age-predicted maximal heart rate ¼ 220 e age of participant). Inaddition, test termination guidelines outlined by the AmericanCollege of Sports Medicine (American College of Sports Medicine,2000) were followed.

For the purpose of data analysis, cardiorespiratory fitness wasdefined in two ways. First, equations published by the AmericanCollege of Sports Medicine (American College of Sports Medicine,2000) were used to estimate the metabolic equivalents (MET)level at which the participant achieved 85% of their age-predictedmaximal heart rate. In addition, the time point during the exercisetest at which the participant achieved 85% of their age-predictedmaximal heart rate was used for data analysis. Increases in METlevel and/or duration of the exercise test are representative ofimprovements in cardiorespiratory fitness.

2.4.5. Body compositionBody composition was evaluated across multiple domains.

Weight was measured using a calibrated medical scale. Followingprocedures outlined by the ACSM’s Guidelines for Exercise Testingand Prescription (American College of Sports Medicine, 2000) andused in our smoking cessation studies of smokers (Marcus et al.,1999, 2005), body fat percentage was assessed using skinfoldthickness measured on the right side at the triceps, suprailiac crest,and thigh using a Lange caliper. Also consistent with ACSMguidelines, body mass index (BMI) was calculated by dividing bodyweight in kilograms by height in meters squared.

2.4.6. Intervention feedback questionnaireThroughout the intervention (at weeks 6 and 12), participants

filled out anonymous, 20-item feedback questionnaires in which

R.A. Brown et al. / Mental Health and Physical Activity 3 (2010) 27e34 31

they rated (on a scale from 1 ¼ strongly disagree to 7 ¼ stronglyagree) their perceptions of staff knowledge, helpfulness, avail-ability, the extent to which exercise will help with abstinence fromdrugs, attainability of goals of the study, and barriers to partici-pating in the study. The questionnaire also included open-endedquestions about the strengths and weakness of the intervention.

Fig. 2. Percent days abstinent from alcohol.

3. Results

3.1. Treatment adherence

Attendance for each week of the exercise intervention is dis-played in Fig. 1. During the 12-week intervention, participantsattended an average of 8.6 (SD¼ 3.9) weekly exercise sessions. Overthe course of the 12-week intervention, participants exercised anaverage of 3.9 (SD ¼ 1.1) days per week. In addition, participantsengaged in an average of 209 (SD¼ 180)minutes of physical activityper week with 147 (SD¼ 100) of these minutes being at an exertionlevel of at least moderate intensity. Further, participants earned anaverage of $86 (SD ¼ 39) for weekly incentives for session atten-dance and completion of self-monitoring forms, and $128 (SD¼ 89)from the fishbowl drawing for attending exercise sessions onconsecutive weeks.

3.2. Drinking and drug outcomes

Fig. 2 displays themean percent days alcohol abstinent (PDA) forpretreatment (3 months prior to beginning the exercise interven-tion), during the 12-week exercise intervention, and the 3 monthsfollowing the end of the intervention. Similarly, Fig. 3 displays themean percent days of drug use abstinence at each of thesetimepoints.

To examine changes in alcohol and drug use at follow-ups,paired sample t-tests were conducted comparing baseline to end oftreatment and 3-months post-intervention on measures of alcoholand drug use PDA. These results suggest that, compared to themean pretreatment percent days abstinent (PDA) for alcohol,significant increases in PDA were observed throughout activetreatment, a difference that was significant statistically at the end ofthe 12-week exercise intervention (t ¼ 2.22, df ¼ 14, p < .05) anda trend toward increased PDA at the 3-month post-interventionfollow-up (t ¼ 2.0, df ¼ 13, p ¼ .07). In terms of percent daysabstinence for drug use, there was a significant increase in PDA(t ¼ 2.96, df ¼ 14, p < .05) at the end of treatment and a trendtoward increased PDA 3-months post-intervention (t ¼ 2.14,df ¼ 13, p ¼ .05).

Fig. 1. Weekly attendance.

While a comparison group is not available for analyzing differ-ences in relapse curves, we examined substance use relapse(defined as any drug or alcohol use) and continuous abstinenceduring the 12-week intervention. At the end of the exercise inter-vention, 66.7% of the sample did not relapse and had beencontinuously abstinent. When examining the entire follow-upperiod, the median days until first use across the entire sample was91 days.

3.3. Relationship between participant attendanceand treatment outcomes

We also examined differences in substance use outcomesbetween participants who attended at least 75% of all sessions (i.e.,8 out of 12 weeks, n ¼ 10; Attenders) and those who attended lessthan 75% of sessions (non-Attenders). A log-rank analysis(Harrington & Fleming,1982) was conducted comparing the risk forrelapse among Attenders and non-Attenders. Non-Attenders weresignificantly (c2 ¼ 11.5, df ¼ 1, p < .001) more likely to relapse thanAttenders (80% vs. 20%, respectively).

3.4. Cardiorespiratory outcomes

Table 1 displays the means and standard deviations of each ofthe cardiorespiratory and body composition measures at baseline,end of treatment, and the 3-month post-intervention follow-up.Paired sample t-test comparisons were conducted to determinewhether there were statistically significant differences betweeneach baseline measure of cardiorespiratory fitness and bodycomposition and their corresponding measure at the end of

Fig. 3. Percent days abstinent from drugs.

Table 1Changes in cardiorespiratory fitness and body composition over time.

Baseline End oftreatment

3-Monthfollow-up

Metabolic Equivalents(METs)*

8.6(2.2) 9.1(3.3) 9.1(2.4)

Duration of ExerciseTest (secs)*

696.2(271.5) 744.9(377.6) 743.8(324.3)

Body Mass Index (BMI) 29.1(10.7) 30.7(11.2) 30.9(11.3)

% Body FatWomen 34.9(4.1) 35.2(4.8) 37.3(.93)Men 19.4(10.1) 19.1(6.6) 21.1(8.9)

Waist-to-Hip Ratio .89(.05) .92(.07) .89(.07)

* Significant differences between baseline and 3-Month Follow-up.Numbers in parentheses reflect standard deviations of the means.

R.A. Brown et al. / Mental Health and Physical Activity 3 (2010) 27e3432

treatment and 3-month assessment timepoints. Compared tobaseline, there was a trend toward participants improving on theduration of the submaximal treadmill test at end of treatment(t ¼ 1.93, df ¼ 12, p < .08) and significant improvement in cardio-respiratory fitness at the 3-month post-intervention follow-up(t ¼ 2.56, df ¼ 11, p < .05). In addition, compared to baseline,participants were able to reach 85% of their maximal heart rate athigher MET levels at the 3-month follow-up (t ¼ 2.62, df ¼ 11,p< .05). No significant differences were observed between baselineand follow-ups on body composition measures.

3.5. Intervention feedback

At week 6 and again at the end of the 12-week intervention,participants filled out an anonymous feedback questionnaire. Onquestions related to positive staff characteristics, participantsreported strongly agreeing (mean ¼ 6.75, SD ¼ .35) with state-ments. Similarly, regarding their perceptions that participating inthe SAE intervention would help their recovery, participants alsostrongly agreed (mean ¼ 6.73, SD ¼ .80). On open-ended questionsregarding the strengths and weaknesses of the program, partici-pants identified positive reinforcement, increased motivation,supportive atmosphere, obtaining more knowledge about exercise,and incentives as strengths. On the other hand, participants iden-tified lack of a strength training and nutritional informationcomponent as weaknesses.

4. Discussion

Relapse continues to pose a major problem to the substanceabuse treatment field as a whole and to individuals attemptingrecovery from drug use disorders. Studies evaluating strategies toenhance maintenance of treatment gains have devoted relativelylittle attention to lifestyle modification, and research in the area ofengaging in physical activity and recovery from drug use disordersis still in its infancy. For over two decades, researchers have calledfor studies examining the role of physical activity in recovery fromsubstance use disorders, yet to date, very little research has beenconducted to specifically examine the application of exerciseinterventions in adults with drug dependence. However, manypatients in substance abuse programs express interest in incorpo-rating exercise into their recovery (Read et al., 2001).

Therefore, to address this existing gap in the literature, wedeveloped an aerobic exercise intervention as an adjunct toaddiction treatment for drug dependent patients. In this pilot study,sedentary drug dependent patients engaged in a 12-week indi-vidually-tailored moderate-intensity aerobic exercise intervention.The preliminary outcomes of this pilot study revealed goodadherence to the exercise intervention with demonstrated benefits

in cardiorespiratory fitness by the end of the 12-week intervention.In addition, compared to baseline, there were significant increasesin percent days abstinence of alcohol and drug use at follow-uptimepoints and participants who attended at least 75% of theexercise sessions had significantly better substance use outcomesthan those who did not.

While we observed promising outcomes among participantsengaged in this intervention, we also noted various challenges inparticipant recruitment and enrollment. It is very likely that ourinclusion and exclusion criteria were overly stringent. Given thesupervised, structured exercise program, including exerciseprescriptions for moderate-intensity exercise, we excluded certainmedical and psychiatric conditions, and were most likely overlyconservative in so doing. The strict inclusion/exclusion criteriarepresent a study limitation that could affect the generalizability ofour findings. Alternatively, we might have done well to seekapproval for participation from patients’ primary care physician orwe might have offered a less intensive intervention that requiredfewer restrictions, such as a program focused on walking andincorporating pedometers. A second, potentially more importantfactor is that despite good intentions and a desire to improve fitnessand remain abstinent, a limited number of participants were unableto meet the time and physical demands of such a program or mayhave preferred other types of exercise. Research focused on betterunderstanding the expectations of this population along withidentifying their specific exercise preferences may be very infor-mative in the refinement of future exercise interventions for drugdependent patients in early recovery. These recruitment challengesmay also point to the need for multisite trials to increase samplesizes for study participation.

Despite these recruitment challenges, a physical activity inter-vention with demonstrated generalizability and the potential fordissemination would have important clinical and public healthimplications for the treatment of drug dependence and providesome definite advantages. Exercise offers the potential forimproved health and wellness, as the physiological (e.g., USDHHS,1996) and psychological (e.g., Stathopoulou, Powers, Berry, Smits,& Otto, 2006) benefits of exercise have been well documented.Exercise also has the potential to be cost-effective, flexible andaccessible; many forms of exercise (e.g., running, fitness video-tapes, swimming)may be conducted independently, either at homeor outdoors, and associated costs are likely to be minimal. Finally,exercise has minimal side effects compared to pharmacologicaltreatment (cf., Broocks et al., 1998). With the use of properprecautions for prevention of injuries (American College of SportsMedicine, 2000), exercise carries with it far less risk of adverseevents than does the use of psychotropic medication.

Limitations of this pilot study include the lack of a control group,a small sample size and a lack of diversity of the study sample whowere primarily Caucasian and largely well-educated. Indeed, thiswork is primarily developmental in nature, and the lack of a controlgroup limits the extent to which one can meaningfully interpret ormake definitive statements about the efficacy of the exerciseintervention. There is also limited ability to examine mediatingmechanisms whereby participation in aerobic exercise may haveled to reduced alcohol and drug use outcomes. In addition, futurestudies should attempt to identify demographic and personalcharacteristics that could limit patient involvement in structuredexercise programs in order to develop physical activity interven-tions that are generalizable to substance abusing patients asa whole. However, the current study has demonstrated the exerciseintervention to be feasible and to generate promising levels ofadherence in a drug dependent population. The efficacy of theexercise intervention warrants further investigation in futurerandomized clinical trials. If the efficacy of this moderate-intensity

R.A. Brown et al. / Mental Health and Physical Activity 3 (2010) 27e34 33

aerobic exercise intervention can be demonstrated, drug depen-dent patients may be provided with a valuable adjunct to tradi-tional substance abuse treatment. Furthermore, future studies maycontribute much-needed knowledge about the role of aerobicexercise in reducing alcohol and drug use and increasing fitness indrug dependent patients.

Acknowledgments

Supported in part by grant DA14599 from the National Instituteon Drug Abuse to Dr. Richard A. Brown.

References

Adinoff, B. (2004). Neurobiologic processes in drug reward and addiction. HarvardReview of Psychiatry, 12, 305e320.

American College of Sports Medicine. (2000). Guidelines for exercise testing andprescription. New York: Lippincott, Williams and Wilkins.

Andlin-Sobocki, P. (2004). Economic evidence in addiction: a review. The EuropeanJournal of Health Economics, 5(Suppl. 1), S5eS12.

Bock, B. C., Marcus, B. H., King, T. K., Borrelli, B., & Roberts, M. R. (1999). Exerciseeffects on withdrawal and mood among women attempting smoking cessation.Addictive Behaviors, 24, 399e410.

Borg, C. (1998). Borg’s perceived exertion and pain scales. Stockholm: HumanKinetics.

Bressan, R. A., & Crippa, J. A. (2005). The role of dopamine in reward and pleasurebehaviourereview of data from preclinical research. Acta Psychiatrica Scandi-navica Supplement, 427, 14e21.

Broocks, A., Bandelow, B., Pekrun, G., George, A., Meyer, T., Bartmann, U., et al.(1998). Comparison of aerobic exercise, clomipramine, and placebo in thetreatment of panic disorder. American Journal of Psychiatry, 155, 603e609.

Brown, R. A., Abrantes, A. M., Read, J. P., Marcus, B. H., Jakicic, J., Strong, D. R., et al.(2009). Aerobic exercise for alcohol recovery: rationale, program description,and preliminary findings. Behavior Modification, 33, 220e249.

Brown, R. A., Monti, P. M., Myers, M. G., Martin, R. A., Rivinus, T., Dubreuil, M. E.,et al. (1998). Depression among cocaine abusers in treatment: relation tococaine and alcohol use and treatment outcome. American Journal of Psychiatry,155, 220e225.

Brownell, K. D., Marlatt, G. A., Lichtenstein, E., & Wilson, G. T. (1986). Understandingand preventing relapse. American Psychologist, 41, 765e782.

Collingwood, T. R., Reynolds, R., Kohl, H. W., Smith, W., & Sloan, S. (1991). Physicalfitness effects on substance abuse risk factors and use patterns. Journal of DrugEducation, 21, 73e84.

Craft, L. L., & Landers, D. M. (1998). The effect of exercise on clinical depression anddepression resulting from mental illness: a meta-analysis. Journal of Sport andExercise Psychology, 20, 339e357.

Dishman, R. K., & O’Connor, P. J. (2009). Lessons in exercise neurobiology: the caseof endorphins. Mental Health and Physical Activity, 2, 4e9.

Donaghy, M., & Mutrie, N. (1998). A randomized controlled study to investigate theeffect of exercise on the physical self-perceptions of problem drinkers. Phys-iotherapy, 84, 169.

Donaghy, M. E., & Ussher, M. H. (2005). Exercise interventions in drug and alcoholrehabilitation. In G. Faulkner, & A. H. Taylor (Eds.), Exercise, health, and mentalhealth: Emerging relationships (pp. 48e69). London, UK: Routledge.

Drummond, S. P., Gillin, J. C., Smith, T. L., & DeModena, A. (1998). The sleep ofabstinent pure primary alcoholic patients: natural course and relationship torelapse. Alcoholism: Clinical and Experimental Research, 22, 1796e1802.

Dunn, A. L., Trivedi, M. H., & O’Neal, H. A. (2001). Physical activity dose-responseeffects on outcomes of depression and anxiety. Medicine & Science in Sports &Exercise, 33(Suppl. 6), S587eS597, discussion 609e610.

Ersche, K. D., & Sahakian, B. J. (2007). The neuropsychology of amphetamine andopiate dependence: implications for treatment. Neuropsychology Review, 17,317e336.

Finney, J. W., Moos, R. H., & Timko, C. (1999). The course of treated and untreatedsubstance use disorders: remission and resolution, relapse and mortality. InB. S. McCrady, & E. E. Epstein (Eds.), Addictions: A comprehensive guidebook (pp.30e49). New York: Oxford University Press.

First, M. B., Spitzer, R. L., Gibbon, M., & Williams, J. B. W. (1995). Structured clinicalinterview for DSM-IV Axis I disorders. New York: New York State PsychiatricInstitute.

Grant, B. F., Stinson, F. S., Dawson, D. A., Chou, S. P., Dufour, M. C., Compton, W., et al.(2004). Prevalence and co-occurrence of substance use disorders and inde-pendent mood and anxiety disorders: results from the National EpidemiologicSurvey on Alcohol and Related Conditions. Archives of General Psychiatry, 61,807e816.

Gruber, S. A., Silveri, M. M., & Yurgelun-Todd, D. A. (2007). Neuropsychologicalconsequences of opiate use. Neuropsychology Review, 17, 299e315.

Harrington, D. P., & Fleming, T. R. (1982). A class of rank test procedures for censoredsurvival data. Biometrika, 69, 553e566.

Hobson, M. L., & Rejeski, W. J. (1993). Does the dose of acute exercise mediate psycho-physiological responses to mental stress? Journal of Sport Psychology, 15, 77e87.

Hunt, W. A., Barnett, L. W., & Branch, L. G. (1971). Relapse rates in addictionprograms. Journal of Clinical Psychology, 27, 455e456.

Jovanovski, D., Erb, S., & Zakzanis, K. K. (2005). Neurocognitive deficits in cocaineusers: a quantitative review of the evidence. Journal of Clinical and ExperimentalNeuropsychology, 27, 189e204.

Keller, S. M. (1980). Physical fitness hastens recovery from psychological stress.Medicine & Science in Sports & Exercise, 12, 118e119.

Kramer, A. F., & Erickson, K. I. (2007). Capitalizing on cortical plasticity: influence ofphysical activity on cognition and brain function. Trends in Cognitive Sciences, 11,342e348.

Langenbucker, J. W., McCrady, B. S., Brick, J., & Esterly, R. (1993). Socioeconomicevaluations of addictions treatment President’s commission on model state druglaws. Washington: President’s Commission on Model State Drug Laws.

Larimer, M. E., Palmer, R. S., & Marlatt, G. A. (1999). Relapse prevention. An overviewof Marlatt’s cognitive-behavioral model. Alcohol Research & Health, 23, 151e160.

Lawlor, D. A., & Hopker, S. W. (2001). The effectiveness of exercise as an interventionin the management of depression: systematic review and meta-regressionanalysis of randomised controlled trials. British Medical Journal, 322, 763e767.

Liu, T., Xiaoping, W., Wei, H., & Zeng, W. (2000). Frequency of withdrawal symptomsof natural detoxification in heroin addicts. Chinese Mental Health Journal, 14,114e116.

McAuley, E., Courneya, K. S., & Lettunich, J. (1991). Effects of acute and long-termexercise on self-efficacy responses in sedentary, middle-aged males andfemales. Gerontologist, 31, 534e542.

McCrady, B. S., & Epstein, E. E. (1999). Introduction. In B. S. McCrady, & E. E. Epstein(Eds.), Addictions: A comprehensive guide book (pp. 3e5). New York: OxfordUniversity Press.

Marcus, B. H., Albrecht, A. E., King, T. K., Parisi, A. F., Pinto, B. M., Roberts, M., et al.(1999). The efficacy of exercise as an aid for smoking cessation in women:a randomized controlled trial. Archives of Intern Medicine, 159, 1229e1234.

Marcus, B. H., Lewis, B. A., Hogan, J., King, T. K., Albrecht, A. E., Bock, B., et al. (2005). Theefficacy of moderate-intensity exercise as an aid for smoking cessation inwomen:a randomized controlled trial. Nicotine and Tobacco Research, 7, 871e880.

Marlatt, G. A. (1985). Lifestyle modification. In G. A. Marlatt, & J. R. Gordon (Eds.),Relapse prevention: Maintenance strategies in the treatment of addictive behaviors.New York: Guilford Press.

Marlatt, G. A., & Donovan, D. M. (2005). Relapse prevention: Maintenance strategies inthe treatment of addictive behaviors (2nd ed.). New York: Guildford Press.

Marlatt, G. A., & Witkiewitz, K. (2005). Relapse prevention for alcohol and drugproblems. In G. A. Marlatt, & D. M. Donovan (Eds.), Relapse prevention: Main-tenance strategies in the treatment of addictive behaviors (2nd ed.). (pp. 1e44)New York: Guildford Press.

Mead, G. E., Morley, W., Campbell, P., Greig, C. A., McMurdo, M. E. T., & Lawlor, D. A.(2009). Exercise for depression. Mental Health and Physical Activity, 2, 95e96.

Meeusen, R. (2005). Exercise and the brain: insight in new therapeutic modalities.Annals of Transplantion, 10, 49e51.

Nunes, E. V., & Levin, F. R. (2004). Treatment of depression in patients with alcoholor other drug dependence: a meta-analysis. Journal of the American MedicalAssociation, 291, 1887e1896.

ONDCP. (2004). The economic costs of drug abuse in the United States 1192e2002.Washington, DC: Executive Office of the President. (Publication No. 207303).

Ouimette, P. C., Gima, K., Moos, R. H., & Finney, J. W. (1999). A comparative evalu-ation of substance abuse treatment IV. The effect of comorbid psychiatricdiagnoses on amount of treatment, continuing care, and 1-year outcomes.Alcoholism: Clinical and Experimental Research, 23, 552e557.

Poling, J., Kosten, T. R., & Sofuoglu, M. (2007). Treatment outcome predictors forcocaine dependence. The American Journal of Drug and Alcohol Abuse, 33,191e206.

Prapavessis, H., Cameron, L., Baldi, J. C., Robinson, S., Borrie, K., Harper, T., et al.(2007). The effects of exercise and nicotine replacement therapy on smokingrates in women. Addictive Behaviors, 32, 1416e1432.

Read, J. P., Brown, R. A., Marcus, B. H., Kahler, C. W., Ramsey, S. E., Dubreuil, M. E.,et al. (2001). Exercise attitudes and behaviors among persons in treatment foralcohol use disorders. Journal of Substance Abuse Treatment, 21, 199e206.

Reed, J., & Ones, D. S. (2006). The effect of acute aerobic exercise on positive acti-vated affect: a meta-analysis. Psychology of Sport and Exercise, 7, 477e514.

Rogers, R. D., & Robbins, T. W. (2001). Investigating the neurocognitive deficitsassociated with chronic drug misuse. Current Opinion in Neurobiology, 11,250e257.

Rotgers, F., Keller, D. S., & Morgenstern, J. (1996). Introduction. In F. Rotgers,D. S. Keller, & J. Morgenstern (Eds.), Treating substance abuse: Theory and tech-nique (pp. 1e12). New York: Guilford Press.

Scott, J. C., Woods, S. P., Matt, G. E., Meyer, R. A., Heaton, R. K., Atkinson, J. H., et al.(2007). Neurocognitive effects of methamphetamine: a critical review andmeta-analysis. Neuropsychology Review, 17, 275e297.

Sinyor, D., Brown, T., Rostant, L., & Seraganian, P. (1982). The role of a physical fitnessprogram in the treatment of alcoholism. Journal of Studies on Alcohol, 43,380e386.

Sobell, L. C., Maisto, S. A., Sobell, M. B., & Cooper, A. M. (1979). Reliability of alcoholabusers’ self-reports of drinking behavior. Behavior Research & Therapy, 17,157e160.

Sobell, L. C., & Sobell, M. B. (1979). Validity of self-reports in three populations ofalcoholics. Journal of Consulting and Clinical Psychology, 46, 901e907.

R.A. Brown et al. / Mental Health and Physical Activity 3 (2010) 27e3434

Sobell, L. C., & Sobell, M. B. (1980). Convergent validity: an approach to increasingconfidence in treatment outcome conclusions with alcohol and drug abusers. InL. C. Sobell, M. B. Sobell, & E. Ward (Eds.), Evaluating alcohol and drug abusetreatment effectiveness: Recent advances (pp.177e183). NewYork: Pergamon Press.

Sobell, L. C., & Sobell, M. B. (1996). Timeline followback: A calendar method forassessing alcohol and drug use. Toronto, Canada: Addiction Research Foundation.

Sobell, M. B., Maisto, S. A., Sobell, L. C., Cooper, A. M., Cooper, T. C., & Sanders, B.(1980). Developing a prototype for evaluating alcohol treatment effectiveness.In L. C. Sobell, M. B. Sobell, & E. Ward (Eds.), Evaluating alcohol and drug abusetreatment effectiveness: Recent advances. New York: Pergamon Press.

Stathopoulou, G., Powers, M. B., Berry, A. C., Smits, J. A., & Otto, M. W. (2006).Exercise interventions for mental health: a quantitative and qualitative review.Clinical Psychology: Science and Practice, 13, 179e193.

Taylor, A. H., Ussher, M. H., & Faulkner, G. (2007). The acute effects of exercise oncigarette cravings, withdrawal symptoms, affect and smoking behaviour:a systematic review. Addiction, 102, 534e543.

Tkachuk, G. A., & Martin, G. L. (1999). Exercise therapy for patients with psychiatricdisorders: research and clinical implications. Professional Psychology: Researchand Practice, 30, 275e282.

USDHHS. (1996). Physical activity and health: A report of the Surgeon General. Atlanta,GA: Centers for Disease Control.

Williams, D. J. (2000). Exercise and substance abuse treatment: predictingprogram completion using logistic regression. Corrections Compendium, 25,4e7.

Witkiewitz, K., & Marlatt, G. A. (2004). Relapse prevention for alcohol anddrug problems: that was Zen, this is Tao. American Psychology, 59,224e235.

Wittchen, H. U., & Jacobi, F. (2005). Size and burden of mental disorders inEuropeea critical review and appraisal of 27 studies. European Neuro-psychopharmacology, 15, 357e376.

Woodard, C. M., & Berry, M. J. (2001). Enhancing adherence to prescribed exercise:structured behavioral interventions in clinical exercise programs. Journal ofCardiopulmonary Rehabilitation, 21, 201e209.

Xie, H., McHugo, G. J., Fox, M. B., & Drake, R. E. (2005). Substance abuse relapse ina ten-year prospective follow-up of clients with mental and substance usedisorders. Psychiatric Services, 56, 1282e1287.

Youngstedt, S. D. (2005). Effects of exercise on sleep. Clinical Journal of SportMedicine, 24, 355e365.