# Exercise as it relates to Disease/Exercise as a treatment for drug addiction

Roessler KK. Exercise treatment for drug abuse-A Danish pilot study. Scand J Pub Health. 2010 Aug;38(6):664-9.

## What is the background to this research?

Australia has a culture which views the abuse of drugs as not overtly harmful to health. This outlook fosters a society that normalises substance misuse and thereby exposes potential addicts to a higher risk of drug addiction. Drug addiction is a significant problem for public health in Australia, with wide social and economic costs. The estimated cost of drug abuse on the Australian economy is $8.2 billion per year. The Australian government focuses less on treatment, prevention, and harm reduction, and more on law enforcement in an effort to combat our drug problem. Despite these efforts, Australia has still recorded more than 2000 drug induced deaths each year for the past five years, and drug deaths are outpacing population growth, implying that our budget split is ineffective. We are in need of evidence to support changes in policy that focus more on prevention and treatment, like Portugal, who saw drug related deaths drop by 80% after extensive policy change.
Exercise has been proposed as a treatment for drug addiction because of its positive effects on health, the possibility to reduce withdrawal symptoms, enhance mood, reduce anxiety and induce reward signalling in the brain. There is a lack of research in this area with well-designed exercise interventions with many participants. The research article by Roessler investigated the use of an exercise intervention as treatment for drug addiction, providing insight into the effectiveness of exercise as treatment for drug addiction and the prospect of conducting more research in the area.

## Where is the research from?

This study was conducted in Denmark by Professor Roessler and was published in 2010. Although social climate differs to Australia, Denmark has approximately half the drug induced deaths of Australia (44 deaths/million people compared to 85 deaths/million people). Therefore, their research has potential use in Australia. Roessler is well published in the area of exercise and substance abuse and this article was published in the Scandinavian Journal for Public Health, which is ranked with its impact factor in the top 71% of journals worldwide. The Scandinavian Journal for Public Health requires all articles to declare whether there is conflict of interest and where any funding came from, but this is not available to read about in the public version of Roessler’s article.

## What kind of research was this?

The study design was an uncontrolled and nonrandomised intervention, which greatly reduces the validity of the results. As such, the level of evidence from studies of this design are considered low. Despite this, as a pilot study, it provides preparation and theory development for a larger scale intervention with an improved study design.

## What did the research involve?

The method for the study was as follows:
* 60 people attending a local drug addiction treatment centre were recruited for the study by workers at the centre. 38 were included in the study.
* VO$_{2max}$, the European Addiction Severity Index questionnaire (EASI), and qualitative focused interviews about sense of body and self-confidence were tested before and after the intervention.
* Participants exercised under the instruction of a university level fitness trainer for two hours, three times a week, for at least eight weeks. The sessions used weight training and exercise bikes and the goal of sessions was to increase maximal oxygen intake.
* One year after the intervention, 23 participants took part in a follow up interview.
The author acknowledges that the methodology of the study was weak. Utilising self-report measures to track drug use increases the risk of social desirability and recall bias effecting the results. Additionally, the exercise sessions were run by the same person over the intervention, which may have made them a social support for the participants and hence influenced participants behaviour towards the exercise sessions. The participants were aware they were being studied, which may have induced the Hawthorn effect (where participants change their behaviour because they aware they are being studied). The participants also had the chance to increase the duration of the intervention beyond the standard eight weeks, which means results could be attributed more to participants who exercised over a longer or shorter intervention span than others.

## What were the basic results?

Important results from the study were as follows:
* Answers from the EASI indicated that fewer participants had the urge to use drugs (65% pre intervention compared to 47% post intervention) and fewer participants had a weakened ability to control their substance abuse (47% pre intervention compared to 18% post intervention).
* In the qualitative interviews, participants described how they felt they suffered less from withdrawal symptoms.
* At the one year follow up interview, five participants stated they were free of substance abuse, 10 said they had reduced intake of drugs and the rest stated no changes in their drug addiction.
The author acknowledges that changes described in the results may be due to other factors. Considering the poor study design and the evidence suggesting that results from uncontrolled studies, such as Roessler’s, may over-estimate intervention effects, conclusions drawn from this study on the effect of exercise as treatment for drug addiction should be interpreted with caution.

## What conclusions can we take from this research?

Whilst conclusions drawn from Roessler’s study must be interpreted with caution, the positive results, albeit offering only low quality evidence, bring attention to a possible area of further research. Roessler’s study produced effects in line with other studies with a similar design, and since publication, more studies with a controlled, randomised design have been conducted, showing positive results in reducing substance misuse in drug addicts. The future of treatment for drug addiction is looking promising and research in this area can hopefully contribute to policy change for managing Australia’s drug problem.

## Practical advice

In conjunction with studies released since Roessler’s it may be suggested that exercise can be utilised as a treatment for drug addiction. A good place to start may be with three sessions per week, each comprised of a five-minute warm up, 30 minutes of moderate intensity aerobic training, 15 minutes of weight training and a five-minute cool down. Medical clearance and having an exercise physiologist oversea the sessions is recommended, as this population may have existing cardiovascular damage which may put them at a higher risk of cardiovascular events when exercising. Starting an exercise program at a low load and progressing slowly may help reduce risk of cardiovascular events.

## Further information/resources

For a review on exercise as treatment for drug addiction, click here.
There is no shame in struggling with addiction - it is a chronic disease that affords just as much respect, dignity and support as other chronic illnesses (cancer, diabetes etc). For resources on help with drug addiction in Australia, click here.

## References

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* ↑ Moore, TJ. Monograph No. 01: What is Australia’s “drug budget”? The policy mix of illicit drug-related government spending in Australia [Internet]. Fitzroy (VIC): Turning Point Alcohol and Drug Centre; 2005 [cited 2020 Sept 11]. Available from: https://ndarc.med.unsw.edu.au/sites/default/files/ndarc/resources/01%20What%20is%20Australia%27s%20Drug%20Budget.pdf
* 1 2 Penington Institute. Australia’s Annual Overdose Report 2019 [Internet]. Melbourne (VIC): Penington Institute; 2019 [cited 2020 Sept 11]. Available from: https://www.penington.org.au/wp-content/uploads/Australias-Annual-Overdose-Report-2019-1.pdf
* ↑ Smith MA, Schmidt KT, Iordanou JC, Mustroph ML. Aerobic exercise decreases the positive-reinforcing effects of cocaine. Drug Alcohol Depend. 2008;98(1-2):129-35.
* ↑ Roberts V, Maddison R, Simpson C, Bullen C, Prapavessis H. The acute effects of exercise on cigarette cravings, withdrawal symptoms, affect, and smoking behaviour: systematic review update and meta-analysis. Psychopharmacol. 2012;222(1):1-15.
* ↑ Cooney GM, Dwan K, Greig CA, Lawlor DA, Rimer J, Waugh FR, et al. Exercise for depression. Cochrane Database Syst Rev. 2013;(9).
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* ↑ Lynch WJ, Peterson AB, Sanchez V, Abel J, Smith MA. Exercise as a novel treatment for drug addiction: a neurobiological and stage-dependent hypothesis. Neurosci Biobehav Rev. 2013;37(8):1622-44.
* ↑ Wang D, Wang Y, Wang Y, Li R, Zhou C. Impact of physical exercise on substance use disorders: a meta-analysis. PloS One. 2014;9(10):e110728.
* ↑ European Monitoring Centre for Drugs and Drug Addiction. Denmark, Country Drug Report 2017 [Internet]. Copenhagen; 2017 [cited 2020 Sept 12]. Available from: https://www.emcdda.europa.eu/system/files/publications/4515/TD0416913ENN.pdf
* ↑ [Internet]. Google Scholar. Kirsten K. Roessler [Internet].; 2020 [cited 2020 Sept 3]. Available from: https://scholar.google.com.au/citations?hl=en&user=y0Xt0pQAAAAJ.
* ↑ SCI Journal. Scandinavian Journal Of Public Health [Internet].; 2019 [cited 2020 Sept 03]. Available from: https://www.scijournal.org/impact-factor-of-scand-j-public-healt.shtml#.
* ↑ SAGE Journal. Scandinavian Journal of Public Health – submit paper [Internet].; 2020 [cited 2020 Sept 03]. Available from: https://journals.sagepub.com/author-instructions/SJP
* ↑ Misra S. Randomized double blind placebo control studies, the “Gold Standard” in intervention based studies. Indian J Sex Transm Dis 2012;33(2):131.
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* ↑ Deeks JJ, Dinnes J, D'Amico R, Sowden AJ, Sakarovitch C, Song F, et al. Evaluating non-randomised intervention studies. Health Technol Assess Rep. 2003;7(27):iii-173.
* ↑ Thabane L, Cambon L, Potvin L, Pommier J, Kivits J, Minary L, et al. Population health intervention research: what is the place for pilot studies? Trials. 2019;20(1):1-6.
* ↑ Althubaiti A. Information bias in health research: definition, pitfalls, and adjustment methods. J Multidiscip Healthc. 2016;9:211.
* ↑ Roessler KK. Exercise treatment for drug abuse-A Danish pilot study. Scand J Pub Health. 2010 Aug;38(6):664-9.
* ↑ Lipsey MW, Wilson DB. The efficacy of psychological, educational, and behavioral treatment: Confirmation from meta-analysis. Am Psychol. 1993;48(12):1181.
* ↑ Burling TA, Seidner AL, Robbins-Sisco D, Krinsky A, Hanser SB. Batter up! Relapse prevention for homeless veteran substance abusers via softball team participation. J Subst Abuse Treat. 1992;4(4):407-13.
* ↑ Li M, Chen K, Mo Z. Use of qigong therapy in the detoxification of heroin addicts. Altern Ther Health Med. 2002;8(1):50-9.
* ↑ Brown RA, Abrantes AM, Read JP, Marcus BH, Jakicic J, Strong DR, et al. A pilot study of aerobic exercise as an adjunctive treatment for drug dependence. Mental Health Phys Act. 2010;3(1):27-34.
* 1 2 3 Rawson RA, Chudzynski J, Mooney L, Gonzales R, Ang A, Dickerson D, et al. Impact of an exercise intervention on methamphetamine use outcomes post-residential treatment care. Drug Alcohol Dependence. 2015;156:21-8.
* 1 2 Muller AE, Clausen T. Group exercise to improve quality of life among substance use disorder patients. Scand J Pub Health. 2015;43(2):146-52.
* 1 2 Trivedi MH, Greer TL, Rethorst CD, Carmody T, Grannemann BD, Walker R, et al. Randomized trial comparing exercise to health education for stimulant use disorder: results from stimulant reduction intervention using dosed exercise. J Clin Psychiat. 2017;78(8):1075.
* ↑ Ghuran A, van Der Wieken L, Nolan J. Cardiovascular complications of recreational drugs: Are an important cause of morbidity and mortality. BMJ. 2001;323:464-6.
* ↑ Franklin BA. Preventing exercise-related cardiovascular events: is a medical examination more urgent for physical activity or inactivity? Am Heart Assoc. 2014;129(10):1081-4