SYSTEMATIC REVIEW

published: 11 March 2022

doi: 10.3389/fpsyt.2022.817927

A Systematic Review of Exercise

Intervention Program for People With
Substance Use Disorder
Zhilei Zhang 1 and Xiujuan Liu 2*
1
Department of Physical Education and Health, Heze University, Heze, China, 2 Department of Politics and Law, Heze
University, Heze, China

Addiction has been attributed to development of habit-based neural circuits that

promote continued substance use despite a conscious wish to abstain. The goal of
this study was to determine if physical exercise could serve as an alternative habit
to replace habitual substance use, and whether this exercise intervention methods
differed for opioid vs. amphetamine Dependents. A total of 14 randomized controlled
experimental literatures on exercise intervention in people with opioid and amphetamine
use disorder were screened, the 14 literature included 4 opioids and 10 amphetamines.
From the 14 literature, the information of intervention program elements were counted,
respectively. Independent sample t-test was used to compare the similarities and
differences between the two intervention methods, and intervention mechanism of
Edited by:
Sergio Machado, dependents were discussed. All rehabilitation exercises for opioid dependents use
Federal University of Santa Maria, aerobic exercise, while most rehabilitation exercises for amphetamine dependents
Brazil
use aerobic exercise, and a few use aerobic and anaerobic mixed exercise. There
Reviewed by:
Martin Zack,
is no significant difference in exercise time, exercise frequency and cycle between
University of Toronto, Canada the two intervention schemes (P > 0.05). The rehabilitation indicators of opioid and
Tara Rezapour,
amphetamine dependents generally include psychological indicators and physiological
Institute for Cognitive Science
Studies, Iran indicators, and most of the tests mainly focus on measuring psychological indicators
*Correspondence: such as mood and drug craving of dependents. The goal of exercise intervention for
Xiujuan Liu opioid and amphetamine dependents is similar, the first is to improve mood, reduce
liuxiujuan81@126.com
craving, improve sleep, and the second is to enhance physical fitness. In the treatment
Specialty section: of Substance use disorder, exercise intervention can be used as an auxiliary treatment.
This article was submitted to Exercise intervention emphasizes low intensity and high frequency. Exercise intervention
Addictive Disorders,
a section of the journal tends to cultivate long-term exercise habits or exercise lifestyle. Based on this "habit"
Frontiers in Psychiatry mechanism, exercise can complete the substitution of material dependence.
Received: 26 November 2021
Keywords: drug dependence, exercise intervention, essential factor, mechanism, plasticity
Accepted: 15 February 2022
Published: 11 March 2022
Citation:
Zhang Z and Liu X (2022) A
INTRODUCTION
Systematic Review of Exercise
Intervention Program for People With
Drug addiction is also known as severe substance use disorder (SUD) or substance dependence. The
Substance Use Disorder. treatment for this kind of substance use disorder costs a lot every year. Based on the psychological
Front. Psychiatry 13:817927. and social mechanisms, Weinstock et al., recommend exercise as an adjuvant therapy for opioid
doi: 10.3389/fpsyt.2022.817927 treatment (1). Physical activity and special exercise are a potential non-pharmacological therapy for

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Zhang and Liu Exercise Intervention Program for Dependents

addiction (2). Exercise intervention, which is an inexpensive Effective substance abuse exercise intervention is a kind
and direct strategy, may have multiple benefits for mental and of exercise prescription with important clinical significance,
physical health. which needs theoretical support and continuous accumulation of
A cross-sectional survey of middle school students across the experience. At present, traditional drugs generally include opium,
United States showed that the decrease in the use of alcohol, heroin and other opioids, while new drugs generally include
cigarettes, and marijuana among students over a period of time methamphetamine and other amphetamine drugs. The exercise
was associated with the increase in exercise volume, and it type, time, cycle, frequency and other exercise elements and
was believed that the participation of exercise and sports teams treatment indicators of the exercise intervention prescriptions
had a synergistic effect in reducing the use of cigarettes and of the two types of substance abusers are counted, respectively,
marijuana (3). A survey of similar high school students found sorted and analyzed, and the two types of exercise intervention
that 80% of the reduction in illegal drug use was related to sports methods are compared to explore the action mechanism of
participation, and participation in sports reduced the overall exercise in substance abuse intervention, which is helpful to
risk of illegal drug use (4). A region at the base of the brain understand and formulate a precise exercise treatment scheme for
striatum, the nucleus accumbens, is the key zone that mediates substance abuse.
the rewarding effects of drugs such as amphetamine and cocaine,
which act directly by increasing the levels of dopamine at this site
(5). Animal experiments showed that physical activity reduced MATERIALS AND METHODS
animals’ self-administration of cocaine, and physical activity
might be an effective intervention in substance use disorder The follow Table 1 for literature sources. The flow diagram of
prevention planning (6). Animal experiments have shown literature retrieval is shown in Figure 1.
that running and chronic cocaine have a common induction
mechanism in the brain’s reward pathways (7). Individuals Statistical Analyses
addicted to alcohol crave alcoholic beverages, spend time seeking The statistical data of various elements of the exercise
alcohol despite negative consequences and eventually drink to intervention program for opioid or amphetamine dependents
intoxication. With prolonged use, control over alcohol seeking were input into spss20.0 software, the two intervention schemes
devolves to dopamine-dependent mechanisms implicated in used independent sample t-test to compare the numerical data
habit learning and individuals in whom alcohol seeking relies in exercise time, exercise frequency and cycle. Other descriptive
more on these mechanisms are more likely to persist in statistics. The addition and subtraction standard deviation of the
seeking alcohol despite the risk of punishment (8). Clinical mean of statistical symbols showed x ± S, and P < 0.05 showed
studies have shown that exercise can be used as a potential significant difference.
intervention tool for substance use disorder, producing beneficial
and durable protection in all stages of substance use disorder.
Exercise can be used as an alternative non-drug reward to RESULTS
compete with drugs and reduce the possibility of their use
(9). Exercise increases dopamine concentration and activates The 14 literature included 4 opioids and 10 amphetamines.
dopamine receptor, which has the same reward pathway as drug From the 14 literature, the information of intervention program
abuse physiologically (10). The duration of positive emotional elements of opioid and amphetamine drug dependents were
state produced by exercise exceeds the duration of exercise counted, respectively, including age (years), exercise time,
(11). In view of the key role of dopamine in the process of exercise frequency, cycle, exercise intensity, exercise content,
addiction, the mechanism of exercise’s influence on dopamine and main rehabilitation indicators. Table 2 (15–18) shows
signaling in the reward pathway can obviously be used as the information list of intervention program elements for
an adjuvant treatment for dependent behaviors. Exercise can opioid dependents. Table 3 (19–28) shows the information
regulate various neurotransmitter systems and intracellular signal list of the intervention program elements of amphetamine-
transduction, increase the level of brain-derived neurotrophic type dependents. Table 4 shows the comparison of the two
factors, promote nerve regeneration and glial cell regeneration, types of intervention program elements. There is no significant
regulate genetic apparent changes, etc., enhance the brain’s difference in exercise time, exercise frequency and cycle between
resistance to addictive substance damage, reduce the brain’s thirst the two intervention schemes (P > 0.05). The two types of
for drugs, and prevent relapse (12). At present, there are many subjects are young and middle-aged. The intervention time
theories about how exercise produces beneficial effects. Although of exercise is mainly 30–50 min, the frequency of exercise is
it is not completely clear, it can be determined that physical generally more than 3 times, and the exercise cycle is generally
activity can be used as preventive intervention for drug abuse more than 3 months. Most studies have reported the control
by improving stress response and emotional regulation (13). range of exercise intensity, which is generally medium and low
Other possible mechanisms include increased socialization, and intensity and does not exceed 80% of the maximum heart rate.
alternative behaviors that exercise a healthy lifestyle. Long-term All rehabilitation exercises for opioid dependents use aerobic
studies have shown that for female individuals who rely on exercise, while most rehabilitation exercises for amphetamine
amphetamine type stimulus, Taijiquan exercise may change their dependents use aerobic exercise, and a few use aerobic and
lifestyle and improve their abstinence ability (14). anaerobic mixed exercise. The rehabilitation indicators of opioid

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Zhang and Liu Exercise Intervention Program for Dependents

TABLE 1 | Literature retrieval list.

Databases China National Knowledge Infrastructure retrieval, PubMed medical literature retrieval service system retrieval, Baidu
academic retrieval
Time frame (year x-y) 2010–2020
Key words of literature retrieval illicit drugs, opioids, opium, heroin, cocaine, amphetamine, methamphetamine, drug dependence, drug rehabilitation,
drug, clinical trial, randomized controlled trial, exercise, sports, motion, and detoxification
Search content Title and abstract
Criteria for inclusion and exclusion The included literature must meet the following conditions at the same time: first, the subjects of the study are opioid or
amphetamine drug dependents. Second, the intervention measures are exercise. Third, the description of exercise
intervention program is more detailed and comprehensive. Fourth, based on the Consolidated Standards of Reporting
Trials statement (CONSORT statement), the 25 items of CONSORT statement were checked
The following studies were excluded: First, similar studies in the same team. Second, acute exercise intervention
research. Third, incomplete or inappropriate exercise intervention information. Fourth, the intervention experiment of
mixed drugs

FIGURE 1 | Flow diagram of literature retrieval.

and amphetamine dependents generally include psychological the nervous and cardiovascular system in many ways (29).
indicators and physiological indicators, and most of the tests The psychological hazards of methamphetamine include
mainly focus on measuring psychological indicators such as amphetamine psychosis, depression, suicide, anxiety, and
mood and drug craving of dependents. violence, while the physical hazards include cardiovascular
and cerebrovascular diseases, dependence and blood-borne
virus transmission (30). Methamphetamine-dependent subjects
DISCUSSION showed extensive depressive symptoms, with an average score of
mild to moderate severity, and adverse mental symptoms were
Exercise Intervention Programs also common (31). It has been generally accepted that physical
Amphetamine-type stimulants (ATS) are obtained by modifying exercise is beneficial to health, the benefits of physical exercise
the chemical structure of ephedrine, which can damage to the brain have also attracted people’s attention. From the

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Zhang and Liu Exercise Intervention Program for Dependents

TABLE 2 | List of information on exercise intervention programs for people with opioid use disorder.

Literature Average age Time Frequency Cycle (days) Intensity Content Index
(years) (minutes) (times/week)

Brown et al. 38.3 30 3 84 69% HRmax Aerobic Heart rate, blood pressure,
(15) exercise metoprolol, BMI, and body fat
Li et al. (17) 30.29 60 3.5 180 Not reported Taijiquan Blood cells, liver function,
kidney function, PAS, and
HRSD
Smelson et al. 36 15 3 14 Not reported Qigong STAI, BDI, and VAS
(16)
Zhuang et al. 29.13 50 5 180 Not reported Yoga POMS and SF-36
(18)
PAS, heroin withdrawal symptom rating scale; HRSD, Hamilton Depression Scale; STAI, state trait anxiety scale; BDI, Beck Depression Scale; VAS, Visual Analog Craving
Scale; POMS, emotional state profile; SF-36, quality of life.

TABLE 3 | Information list of exercise intervention programs for people with amphetamine use disorder.

Literature Average age Time (minutes) Frequency Cycle (days) Intensity Content Index
(years) (times/week)

Dolezal et al. (19) 33 60 3 56 Lactate Jogging and resistance HRV8 VO2max

threshold heart training
rate -HRmax
Richard et al. 31.7 60 3 56 60–80% HRmax Aerobic exercise and BDI and BAI
(32) resistance training
Li et al. (21) 35.4 50 7 168 Not reported Rehabilitation exercises and CogState
functional training
Robertson et al. 29 60 3 56 Not reported Jogging and resistance Utilization ratio of D2/D3
(22) training receptors in striatum
Zhu et al. (23) 37.47 50 5 84 100 Taijiquan Body fat, balance, and QOL-DA
Wang et al. (33) 32.20 35 3 84 65–75% HRmax aerobic exercise VO2max8 HAMA, BDI, and VAS
Zhang et al. (34) 36.49 40 3 84 65–75% HRmax Bicycle, jogging, and CogState and total antioxidant
skipping rope capacity of serum
Liang et al. (26) 27.1 40 3 90 Moderate Yoga and aerobics QOL-DA, SDS, and SAS
intensity
Lu et al. (27) 31.47 90 5 84 40–80% HRmax Moderate intensity exercise SCL-90, SDS, SAS, VAS, and
and resistance training blood index
Liu et al. (28) 18–35 30 2 70 65–75% HRmax Dance and power bicycle LFPQ and Clue task
HRmax, maximum heart rate; HRV, heart rate variability; VO2max, maximum oxygen uptake; BDI, Beck Depression Scale; BAI, baker anxiety scale; CogState, cognitive
scale; QOL-DA, quality of life of drug addiction; HAMA, Hamilton Anxiety Scale; VAS, Visual Analog Craving Scale; SDS, self-rating depression scale; SAS, Self-Rating
Anxiety Scale; SCL-90, symptom checklist 90; LFPQ, Leeds Food Preference Questionnaire.

TABLE 4 | Comparative table of exercise intervention programs for people with opioid and amphetamine use disorder, (x̄ ± S, n = 12).

Exercise elements OUD (n = 4) AUD (n = 1) t P

Time (minutes) 37.50 ± 22.17 51.50 ± 17.32 −1.27 0.23

Frequency (times) 3.63 ± 0.95 3.70 ± 1.49 −0.09 0.93
Period (days) 114.50 ± 80.85 83.20 ± 32.72 1.07 0.31
Intensity (reporting rate) 1(25%) 8(80%)
Sports content (composition ratio) 100% aerobic 100% aerobic
0% anaerobic 40% anaerobic
Intervention indicators (composition ratio) 50% physiological index 40% physiological index
75% psychological index 90% psychological index
Sports content (composition ratio) and intervention index (composition ratio) are multiple choices, people with opioid use disorder (OUD), and people with amphetamine
use disorder (AUD).

rehabilitation indicators of drug dependents involved in exercise, promote psychological benefits: aerobic exercise, no competition
the first is to improve mood, reduce craving and other auxiliary between people, closed activities, and moderate intensity, at
treatments to improve mental health, quality of life and delay least 20 or 30 min, and regular practice (36). Most of the
disease development, and the second is to enhance physical exercise intervention programs for the dependent people are
fitness and monitor cardiovascular system function. low-intensity, multi-frequency exercises with flexible exercise
How can exercise produce the greatest psychological effect? time, which meets the above requirements. In order to facilitate
EBgrer et al. (35) put forward an experimental model to practical operation, intervention programs generally use heart

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Zhang and Liu Exercise Intervention Program for Dependents

rate indicators to control and measure exercise intensity, and Exercise Intervention "Habit" Mechanism
exercise risk prevention and control is carried out at no higher Repeated medication leads to the individual changing from
than a specific heart rate. Drug-dependent patients have low reward effect to habitual mode (44). Using drug can improve
aerobic capacity, so it is very important for them to receive negative emotions such as anxiety, depression and despair, so
physiological treatment in clinic. Some studies suggest that high- some people tend to abuse drugs. Most drug abusers have obvious
intensity interval training should be taken as a part of clinical mental disorders and psychological problems, lack trust in others
practice (37). However, there is a risk of cardiovascular disease. and society, live emptiness, and escape through drug abuse.
In practice, aerobic exercise is generally dominant, which may Although the causes of this phenomenon are very complex, drug
be related to exercise risk control. Studies have shown that abuse is obviously a comprehensive physiological and behavioral
there is no significant difference between low-intensity, medium- response of the dependent (45). Repeated medication forms
intensity and high-intensity exercise to intervene substance the reward pathway of "craving-driving-behavior-reward," and
abuse (nicotine, illegal drugs) (38). There are also studies its neural structure is mainly located in the dopamine (DA)
that moderate-intensity aerobic exercise is the best exercise system at the midbrain edge, which is the core pathway to
intensity for methamphetamine (commonly known as meth) form reward effect (46). After the dependents use illegal drugs,
dependents to recover (39). Behavioral research shows that the the drugs directly stimulate the nervous system, which makes
influence of acute exercise on cognitive performance and brain people feel very happy and temporarily get rid of or forget the
response varies with different exercise intensity: in general, the troubles in reality. Because, they meet the physical and mental
smaller the exercise intensity, the better the improvement effect needs of the abusers, they form positive reinforcement. However,
(40). Relevant research conclusions are inconsistent, and more after the lack of drug stimulation, the dependent people have
evidence is needed. It is worth noting that the physical quality severe discomfort of withdrawal symptoms, strong psychological
of those who depend on it is generally poor, and the heart and craving for drugs, and troubles that can’t escape from reality.
lung functions related to exercise are generally seriously deficient. This painful experience has formed negative reinforcement.
The safety risks will be very prominent if you take intensive The communication between human spirit and body is very
physical exercise. complicated. When such abuse behavior is carried out for a long
Exercise intervention is an auxiliary treatment. Illegal time, replacing the original brain natural reward or showing new
Substance use disorder, a serious social problem, urges reward, the dependence behavior of euphoria becomes a habit.
researchers to innovate methods for rehabilitation. Meta- Every habit has plasticity. Moving from a drug-dependent
analysis provides strong evidence, which shows that physical lifestyle to a drug-free lifestyle, sports services can play an
exercise is an effective method for adjunctive treatment of important role. Dependence behavior is an extraordinary hobby
alcoholics, nicotine and illegal drug dependents, and also and habit (47). By observing, adjusting hints and rewards, we can
reduces withdrawal symptoms (38). Exercise may have many change our usual behaviors and rebuild our habits. Researchers
different mechanisms, which are beneficial to the rehabilitation at the Massachusetts Institute of Technology found a simple
of drug-dependent patients. First of all, exercise can help people neural logic circuit in each habit, which consists of three parts,
experience positive emotions, and depression symptoms are suggestion, habitual behavior, and reward. The golden rule of
associated with poor treatment results. In addition, exercise changing habits is: using the same hints, offering the same
can alleviate sleep disorders, increase self-esteem and reduce rewards, and inserting new habitual behaviors, you can replace
stress response, which may help reduce the risk of relapse of old habits with new habits (48). The formed exercise habit
drug-dependent patients, so exercise is used as an intervention behavior pattern will stay in the brain forever, suppress nerve
measure to prevent relapse of Substance use disorder (15). From activity, control habit loop, and suppress bad habits behind the
more data seem to support the potential benefit of physical scenes. With the birth of a new pattern, exercise can become
exercise as an adjunct in Substance use disorder rehabilitation a natural activity. In the normal situation, a prepared habit
process now (41). To examine, from behavioral perspectives, can be held in check, to allow the slower, more reflective,
the feasibility of applying group-based aerobic exercise as an goal-directed process to override it and occur instead (49).
adjunct to treatment aimed at improving the of substance use
disorder patients (42). In addition, Substance use disorder is
also a chronic encephalopathy, with complicated etiology, long
course of treatment and high relapse rate. Low-intensity and
high-frequency exercise intervention may develop long-term
exercise habits and exercise lifestyle, which is beneficial for drug
dependents to return to society.
Substance use disorder treatment calls for individualized
treatment plan, increases the initiative of participating in
treatment, and provides more comprehensive care for patients.
Investigation shows that during early rehabilitation, the rate of
regular exercise is low, and the level of interest in sports is high,
FIGURE 2 | Mechanism diagram of illegal drug use habit replaced by exercise
so the exercise program can be made according to individual’s
habit.
unique preferences (43).

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Zhang and Liu Exercise Intervention Program for Dependents

Therefore, it is feasible to replace drug abuse habits with exercise dependents (P > 0.05). The goal of exercise intervention is
habits. Because of the plasticity of midbrain marginal reward similar, the first is to improve mood, reduce craving, improve
pathway, the formation of exercise habits may help to reduce sleep, and the second is to enhance physical fitness. In the
drug abuse dependence and change the reward effect of drug treatment of Substance use disorder, exercise intervention can be
abuse, which may help to reduce the incidence and severity of used as an auxiliary treatment. Exercise intervention emphasizes
drug abuse disorder and help to cope with stress successfully (50). low intensity, high frequency, and long-term exercise habit or
Studies have shown that there is a significant positive correlation sports lifestyle. Based on the "exercise habit" mechanism, exercise
between the frequency and amount of physical activity and the may complete the substitution of Substance use disorder.
rehabilitation of Substance use disorder withdrawal (51). There is
evidence that the mental health level of female heroin dependents
can be improved through the regulation of "exercise habits" LIMITATIONS
(52). Regular exercise to intervene substance dependent people
is actually the cultivation of a healthy "exercise habits" (53, 54). This study is helpful to understand and formulate a precise
Teenagers’ preference for sports may be easier to form habits exercise intervention program for drug abuse, but an important
than adults. Therefore, if people participate in sports and achieve limitation is that the literature review does not evaluate the
good emotional effects, avoid negative emotions, and play a role therapeutic effect of exercise intervention program and does not
in self-defense and self-protection, sports can contribute as an know which indicators are of therapeutic significance. It is a good
alternative means of drug abuse (55). The "habit" mechanism solution to evaluate the efficacy of exercise intervention program
of exercise intervention in substance use disorder is shown in on individual indicators through meta-analysis.
Figure 2.
Rebuilding habits cannot be done once and for all. People
who have successfully quit drinking will relapse when faced DATA AVAILABILITY STATEMENT
with a stressful event again. No matter how many new habitual
behaviors they have developed, their habits will never disappear. The original contributions presented in the study are included
Its old habits have not disappeared, it has only been replaced by in the article/supplementary material, further inquiries can be
new habits. That is to say, new habits are not created out of thin directed to the corresponding author.
air, but new habitual behaviors are substituted for old behaviors
by splitting habit loops. Behaviorists and psychological scientists
advocate treating the abuse of illegal drugs as a bad behavior,
AUTHOR CONTRIBUTIONS
that is, paying attention to the important role of psychological
rehabilitation of dependents in the process of withdrawal, and ZZ contributed to the idea for the article, organized the study, and
striving to strengthen psychological counseling and behavior wrote the manuscript. XL helped with the analysis. Both authors
shaping of dependents (56). New drugs are also called party contributed to the article and approved the submitted version.
drugs. In China, most of the behaviors of taking new drugs are
group behaviors (57). Collective exercise in sports can establish
contact with peers, form a mutually restrained group, and reduce
the tendency to use drugs due to self-isolation (58), which is often
FUNDING
very meaningful for those who depend on it to quit illegal drugs. This work was supported by Key Project of the 13th Five Year
In particular, sports can screen and optimize communication Plan of Education Science in Shandong Province (2020zd036).
groups and reduce the possibility of contact with illegal drugs.

CONCLUSION ACKNOWLEDGMENTS
There is no significant difference in the elements of exercise Special thanks to Zhu Dong of Shanghai University of Sport for
time, frequency and cycle between opioid and amphetamine his guidance and inspiration in writing the manuscript.

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