Fotis Panagiotounis
Department of Education, KETHEA, Greece, email: panagiotounisfotis@gmail.com
DOI: https://doi.org/10.57160/BYMY6433
Introduction
Regular physical activity has been linked to multiple benefits for the treatment of substance use disorders in recent years, with a number of studies demonstrating its multifaceted role (Thompson et al., 2020). Indeed, there is evidence to suggest that exercise, via psychological, behavioural, and physiological mechanisms, improves many different aspects of the physical and mental health of people living with Substance Use Disorders (SUD), resulting in improved well-being and quality of life. In this regard, the United Nations Office on Drugs and Crime (UNODC, 2017) recommends its use as an important and integral part of prevention and treatment, citing it as a very promising, affordable, and easily accessible complementary treatment option.
Exercise, in particular, works perfectly in supporting individuals undergoing SUD recovery, offering significant physical, psychological, and social benefits. Exercise can cause pleasurable states, with changes in neurotransmission, while contributing to the normalization of changes in glutamic and dopaminergic signalling observed in mono paths from prolonged abstinence from substance use, thus reducing relapse vulnerability (Zschucke et al., 2012; Lynch et al., 2010). Furthermore, exercise can assist individuals living with SUD in “feeling” their bodies differently and intending to regain their body image before substance abuse (Diamantis et al., 2017; Roessler, 2010). Concurrently, through exercise, they can manage their weight, improve their fitness, and regain their vitality, likely resulting in an improved quality of life and more optimistic prospects for the future (Giménez-Meseguer et al., 2015; Roessler, 2010; Muller & Clausen, 2015).
At the same time, as substance abuse can be interpreted as a non-adaptive coping strategy for stressful, unpleasant, and difficult situations, exercise has been proposed to provide alternative coping strategies for these unpleasant emotions (Zschucke et al., 2012; Lynch et al., 2010).
As the craving for substance use is a key factor in relapse and discontinuation of recovery, the search for strategies and tools to address it is a major concern, especially during the early-stage recovery. Studies in this area suggest that exercise can effectively alleviate levels of craving for substance use by enhancing abstinence (Buchowski et al., 2011; Brown et al., 2010; Ellingsen et al., 2020; Giménez-Meseguer et al., 2015; Zschucke et al., 2012; Panagiotounis et al., 2022a; Roessler, 2010; Wang et al., 2014).
When it comes to mental health, negative mood, anxiety, stress, and depression are all negative prognostic factors for recovery outcomes because they are linked to a high risk of relapse. According to current research, the beneficial effects of exercise appear to contribute to the effective management and reduction of anxiety and depression symptoms in individuals living with SUD (Caviness et al., 2013; Ellingsen et al., 2020; Giménez-Meseguer et al., 2015; Panagiotounis et al., 2022a; Wang et al., 2014; Zschucke et al., 2012). Research has shown that individuals living with SUD with high baseline cognition and low baseline depression are less likely to benefit from exercise (Rethorst et al., 2021).
A non-drug-related social network is frequently important in preventing relapse (Stevens et al., 2015; Spohr et al., 2019). Individuals living with SUD are socially isolated during recovery because they coexist with a small number of people in their daily lives (Roessler, 2010). Participating in group exercise programs can assist them in improving their communication skills, developing positive interpersonal relationships, managing conflict, and tolerating frustration, resulting in a significant improvement in the social domain of their quality of life (Zschucke et al., 2012; Giménez-Meseguer et al., 2015).
Another way that exercise appears to benefit individuals living with SUD is that it improves their self-concept. Individuals living with SUD have low self-efficacy and self-esteem. Exercise may improve an individual’s ability to maintain abstinence by increasing their effectiveness through a sense of accomplishment (Caviness et al., 2013; Giménez-Meseguer et al., 2015; Panagiotounis et al., 2020; Weinstock et al., 2017).
Finally, exercise and sport can provide a safe learning environment in which targeted interventions can be implemented to train individuals living with SUD in behavioral change and skill development strategies (Panagiotounis et al., 2022b) that they can apply to other aspects of their lives, such as work and education (formal and non-formal). Additionally, it seems that exercise improves working memory (Chen et al., 2021).
To achieve optimal integration of the benefits of exercise and sport into SUD recovery, key factors such as, among others, the contribution and training of all stakeholders for the proper implementation of exercise and sport programs, the integration of research into clinical services to evaluate and ensure that the exercise programs a) are based on scientific data and b) adequately meet the purpose for which they were implemented, are required.
Recommendations for practical application are aimed at SUD recovery providers and SUD recovery counselors, including sports educators working in the field, as well as future researchers who want to explore the field, to provide the appropriate support to improve their services, whether that means developing and supporting new integrated exercise programs that do not currently exist or improving existing ones. This includes addressing the difficulties of designing, implementing, and evaluating exercise programs, thereby facilitating their incorporation into SUD recovery.
SUD recovery providers
Individual therapy, group counseling, and medication are among the services offered by SUD recovery providers, who also often urge involvement in support groups. Many SUD recovery providers are emphasizing the need to integrate exercise and physical activity into treatment plans in this framework since it is believed that enhancing individuals’ physical health will allow them to establish and continue recovery.
While many SUD recovery providers recognize the need of establishing health promotion programs for individuals living with SUD, many see it as a challenge that must be overcome by devoting or investing financial and human resources. Exercise interventions in the SUD recovery process lack a defined implementation framework as a direct and indirect outcome of this approach.
Health promotion
The World Health Organization defines health as a state of complete physical, social, and mental well-being, rather than simply the absence of any illness or disability. In this context, health promotion is defined as a process that allows people to improve their health by encouraging lifestyle changes, and it extends beyond focusing on individual behaviour to include a broader range of social and environmental interventions. Health promotion aids in the reduction of excess mortality, addresses health determinants, and strengthens sustainable health systems (WHO, 2017).
Recommendation 1: It is recommended that SUD recovery providers facilitate and enhance health behaviour promotion, such as exercise, nutrition, weight control, and so on, in order to provide the required conditions for individuals living with SUD to achieve optimal health and well-being.
Recommendation 2: It is recommended that SUD recovery providers identify and secure both human and material resources to support health-promoting interventions such as physical exercise and sport, by ensuring that exercise guidelines are followed and incorporated to the maximum extent possible (WHO, 2020).
Recommendation 3: It is recommended that SUD recovery providers make (or facilitate access to) quality sports and exercise facilities and services available to their clients.
Recommendation 4: It is recommended that SUD recovery providers provide training and guidance to their staff in order for them to plan, implement, and evaluate initiatives that promote healthy behaviours in the target population. In this context, they should identify and provide the fundamental skills and knowledge required to improve the efficacy of exercise and sport programs in the SUD recovery.
Adolescents and young adults
Despite the fact that there is no universally accepted therapeutic approach for adolescents and young adults with SUD, exercise and sport can aid in the management of the physiological, psychological, and sociological issues that contribute to substance use involvement.
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Recommendation 1: It is recommended that exercise and sports interventions be developed with the goal of minimizing harm, abstaining from substance use, enhancing learning, improving interpersonal relationships, and overall improving the physical and mental health of adolescents and young adults who use substances.
Cooperation for health promotion
Collaboration for health promotion is a practice in which all stakeholders benefit from the exchange of experiences and knowledge in order to achieve more effective and efficient healthier behaviour interventions.
Recommendation 1: It is recommended that the design, implementation, and evaluation of exercise interventions in SUD recovery be supported by an interdisciplinary team from the fields of exercise, psychology, addictions, and research, leveraging the strengths of each field’s unique perspectives.
Development of cross-sectoral cooperation
Cross-sectoral collaboration is a joint effort in which experts from a variety of scientific and professional sectors combine their efforts to develop shared opportunities for improved health promotion.
Recommendation 1: It is recommended that exercise and sports interventions be developed with the goal of minimizing harm, abstaining from substance use, enhancing learning, improving interpersonal relationships, and overall improving the physical and mental health of adolescents and young adults who use substances.
SUD recovery counsellors
As they interact with this population on a daily basis, SUD recovery counsellors working in various therapeutic contexts have the potential to play a key role in promoting exercise. Counselling is used to assist individuals living with SUD in developing healthier, more adaptable attitudes and behaviours that will support their long-term abstinence from substance use. Exercise provides an alternative environment in which individuals living with SUD can adopt new healthy behaviours that do not involve substance use. Counsellors can improve recovery effectiveness in this context by utilizing different and more appealing approaches, such as encouraging participation in exercise and sports programs during the SUD recovery process.
However, SUD recovery counsellors may be unable to understand and apply alternative approaches, such as participating in exercise and sports programs, to improve SUD recovery outcomes (Panagiotounis et al., 2022c). The recommendations that follow contain specific basic, but also practical elements that increase the value and utilization of exercise and sports during the recovery process, thereby improving the effectiveness of services provided by counsellors and, as a result, SUD recovery providers.
Exercise and sport participation promotion
Recommendation 1: It is recommended that recovery counsellors provide opportunities and ensure access to exercise and sport programs for individuals undergoing SUD recovery.
Readiness to exercise and sport participation
Recommendation 1: It is recommended that recovery counsellors assess a client’s readiness to participate in the exercise, particularly during the early stages of treatment, with the goal of not only achieving exercise engagement but also retaining it.
Motivation for exercise engagement
Recommendation 1: Clients should be actively involved in the formulation of sports and exercise interventions, as well as the development of progress indicators that are appropriate for them, based on their recovery goals.
Recommendation 2: Motivational strategies should be used by recovery counsellors to encourage clients to participate in exercise programs. In this context, interventions that promote motivation and behaviour change are recommended in order to successfully extend exercise experiences in SUD recovery.
Interdisciplinary
Recommendation 1: To promote and appropriately apply exercise and sport interventions in the SUD recovery, counsellors may seek and use interdisciplinary collaboration.
Connection with the recovery stages goals
Recovery counsellors may promote exercise as a part of recovery, establishing a link between therapeutic and exercise goals. As a result, the counsellors must ensure that the clients set realistic exercise goals that do not compromise their recovery. To do so, the counsellors must be able to manage the client’s expectations regarding exercise, as well as the consequences of doing so (Weinstock et al., 2017).
Recommendation 1: Recovery counsellors are recommended to encourage exercise and sports involvement throughout the treatment process, emphasising the link between therapeutic and exercise/sport goals.
Recommendation 2: It is recommended that exercise and sport interventions be tailored to the needs and challenges faced at the different stages of the SUD recovery process.
Early-stage of recovery
Exercise and sport, according to Williams and Strean (2004), should complement and be directly related to therapeutic goals. Since relapse rates are higher in the first three months of recovery, exercising and participating in sports can help to reduce the risk of relapse (Abrantes & Blevins, 2019). Indeed, during the first weeks of treatment, when withdrawal syndrome comes in, the craving to use, along with a negative mood, leads to relapse and dropping out of recovery. Body harm and poor physical health contribute to a significant portion of the negative mood, with recovery being a top priority in the early stages (Diamantis et al., 2017).
In this context, exercise and sports engagement are recommended as a self-control strategy for addressing withdrawal symptoms as well as a strategy for recovering from the harm caused by drug abuse (Abrantes & Blevins, 2019; Linke & Ussher, 2015). It should be noted, however, that if relapse occurs too early, an exercise intervention may not be able to affect the relapse prevention process (Abrantes & Blevins, 2019).
Recommendation 1: Exercise and sport programmes should be considered and integrated in the acute practices of the available design support repertoire of the early stage of recovery.
Recovery engagement
Recommendation 1: In the early stages of recovery, it is recommended that exercise and sport initiatives be provided primarily as a “here and now” intervention, aimed at enhancing engagement in the recovery process and acting as a complement to proper management of negative factors (craving, stress, anxiety, depression, negative thoughts, etc.) that may lead to drop-out from the recovery process.
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Enhancement of quality of life
Long-term substance abuse has a negative impact on an individual’s general well-being and quality of life. The low quality of life that characterizes individuals living with SUD acts as a deterrent to active treatment engagement, eventually leading to treatment drop-out.
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Recommendation 1: Recovery counsellors are recommended to utilize exercise and sports engagement to enhance physical and mental well-being, as well as social functionality, in the early stage of recovery, hence increasing the overall quality of life of individuals living with SUD.
The second stage of recovery
The second stage of recovery focuses on achieving psychosocial, behavioural, and cognitive changes while aiming at training and supporting individuals living with SUD to stabilize and maintain these changes over time. In this perspective, the enhancement of mental, physical, and emotional skills, helps to enhance self-efficacy, leading to better management of negative feelings that were present in the previous initial stage. Parallel to the above, at this stage, social skill development is attempted with the goal of redefining social support networks.
Participating in exercise and sports programs is beneficial to individuals undergoing SUD recovery not only for enjoyable leisure management, but also because it can improve self-efficacy, self- esteem, and quality of life both during and after recovery, as well as provide a sense of “belonging” by promoting a different way of rebuilding relationships with others.
To be defined as a life skill, a skill must be transferable to other life domains than the one taught, and the educational process must facilitate this transfer (Goudas, 2010; Gould & Carson, 2008). Exercise and sport are suitable environments for learning and practicing the skills required in everyday life.
Recommendation 1: Recovery counsellors are recommended to combine the exercise experience with coping with everyday actual problems.
Recommendation 2: Recovery counsellors are recommended to use exercise and sports experiences to develop their clients’ social and other life skills, preparing them for sustainable social reintegration.
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The final stage of recovery
The final stage of recovery aims at sustainable social reintegration. Exercise and sport are both effective tools for personal development because they provide an alternative, but also safe, learning environment for the development of skills such as control and time management skills, communication skills, social skills, collaboration, leadership, problem-solving, goal-setting, and so on, which will aid the individual in both successful social reintegration and effective management of the complexity of life’s reality. Through well-tailored exercise and sport programs, which can lead to the development of these skills, combined with focused counselling (experiential learning techniques), counsellors can train their clients to transfer these skills into their daily lives.
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Enhancing employability
Participation in sport represents a unique opportunity for individuals living with SUD to develop transversal skills that may positively affect their personal development, enhancing the potential for sustainable employment and the development of conditions that will facilitate a sustainable reintegration into society. Communication skills, cooperative skills, leadership, control, management, problem-solving skills, social skills, goal-achieving skills, etc., are examples of such skills (Opstoel et al., 2019).
Recommendation 1: Individuals living with SUD should be encouraged to participate in exercise and sport programmes as they provide an easily accessible setting for developing skills that can be transferred to the workplace.
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Social Reintegration
Recommendation 1: Recovery counsellors are recommended to encourage their clients’ engagement in sports clubs as a safe strategy to integrate into society and social networking.
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Adoption of healthy habits and lifestyle
The return of old behaviours following SUD treatment might present challenges to individual recovery and general well-being. In this framework, it might be helpful to engage in different types of aftercare, relapse prevention, and general recovery support to stay on course. The SUD recovery is a continuous process of change, which includes a variety of complementary behaviour change interventions. Adopting a healthy lifestyle is a key component of this process. Maintaining the healthy practices started in treatment is crucial to living a life of fulfilment and happiness, and one of the healthiest habits to continue is frequent exercise and sport participation.
Exercise’s long-term impacts are linked to the adoption of lifetime healthy habits and lifestyles. However, health interventions focused on behaviour change in individuals living with SUD are unlikely to be as effective as those directed at other populations. According to Roessler (2010), the majority of clients who completed an exercise program returned to substance use once the program ended. In this framework, providing support beyond the end of recovery is essential for lifelong engagement in exercise. Indeed, it is unclear to what extent exercise engagement can be maintained during the transition and reintegration into society (More, 2017).
Wang et al. (2014), on the other hand, argued in their study that exercise has a long-term impact on SUD recovery, which is likely related to the effects of exercise that may lead to structural changes. Undoubtedly, although participation in an exercise program cannot promote the adoption of healthy habits on its own, it may provide clients with a sense of control over the period in which the clients participate in the exercise program and consequently in recovery (Roessler, 2010).
Recommendation 1: Counsellors in the last stages of recovery are recommended to encourage their clients to engage in long-term physical exercise, therefore increasing the likelihood of lifetime adoption.
Recommendation 2: It is recommended that recovery counsellors enhance commitment since it is a vital component of establishing change and subsequent adoption of healthy behaviours. This commitment may have a long-term impact on the long-term impacts of participation in an exercise and sport programme, enhancing the individual’s lifelong adoption of healthy behaviours.
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Sport Trainers
It is undeniable that highly qualified sports coaches are the most “important aspect” of implementing exercise interventions in SUD recovery. As a result, their presence is considered essential to the successful implementation of exercise programs. The most important factors which go into developing exercise programs for this population are listed below.
Exercise intensity
As a result of their poor quality of life-related to drug abuse, individuals undergoing SUD recovery face considerable physical and psychological challenges, especially in the early recovery stages (Linke & Ussher, 2015). Also, these individuals follow a predominantly sedentary lifestyle, as they may not perform any physical activity (Weinstock et al., 2017). Research to date has shown that high-intensity programs have low compliance rates compared to low- and moderate-intensity programs, which are preferred by this population (Abrantes et al., 2011). It should also be noted that moderate-intensity physical activity appears to have a positive effect on craving and improving abstinence from substances (Zhang et al., 2021; Wang, 2019).
Recommendation 1: On the basis of the available literature, it is recommended that the initial engagement with exercise be educational, emphasizing the benefits of frequent intervals of moderate physical activity of short duration, and suggesting walking as a preliminary type of exercise during the early stages of recovery.
Recommendation 2: In the later stages of treatment, it is recommended to strengthen the voluntary participation in moderate-intensity exercise, acting protectively, and reducing the risk of injury or other side effects.
Recommendation 3: Even for individuals who initially refuse exercise, the increase in exercise intensity should be moderate, acting as a challenge, to avoid early withdrawal and abandonment.
Type of exercise
To date, research has suggested that aerobic exercise (Buchowski et al., 2011; Beynon et al., 2013; Brown et al., 2010), strength training (Abrantes et al., 2011), and mind-body exercises (Wang et al., 2014) are all acceptable options for SUD recovery. Furthermore, simple walking was one of the most popular activities among those recovering from SUD (Abrantes et al., 2011). Also, an important form of exercise used in SUD recovery is outdoor sports adventure activities, with significant therapeutic outcomes (Panagiotounis et al., 2020). Regarding team sports, according to Diamantis et al. (2017), the sense of play was mentioned as an important aspect of satisfaction, however, there is a lack of data to support it further. It should also be noted that it is important to ask individuals, to identify the activities which they experienced in the past and which led to feelings of enjoyment, so that then they can gradually integrate into their lifestyle in ways compatible with individual recovery planning. However, these activities should be carefully evaluated by sport trainers and SUD recovery counsellors, as they may be strongly associated with a drug abuse lifestyle (Williams & Strean, 2004).
Recommendation 1: On the basis of the available literature, aerobic exercise, strengthening exercises, mind-body exercises, and outdoor adventure sports activities are all recommended types of exercise.
Recommendation 2: On the basis of the available literature, simple walking is recommended as a primary and safe choice for clients in poor physical condition or with limited motor function. In addition, team sports are advised as an important component of an exercise program for SUD recovery.
Recommendation 3: On the basis of the available literature, it is recommended that outdoor adventure activities tailored to this population incorporate activities that are defined by a high level of difficulty, enhancing a sense of accomplishment in a structured and controlled manner.
Recommendation 3: Previous exercising experiences should be explored in depth because they may be strongly linked to lifestyle when using substances.
Substance of use
Wang et al. (2014) found significant differences in regard to the type of drug used, with exercise having a greater effect on the rate of abstinence from illegal substances than alcohol and nicotine. The varied addictive processes linked with each type of addiction might be one reason for this effect. Different exercise programs have been implemented in different subgroups of clients based on the major illegal drug of use. The findings of Buchowski et al., (2011) suggest that those who use cannabis have positive benefits after completing an exercise program. Rawson et al. (2015) found positive results in a study of methamphetamine users.
Recommendation 1: Regardless of the primary substance of use, encouraging exercise participation is recommended based on the available literature.
Recommendation 2: To protect the clients’ health, regular monitoring and assessment of the physical and mental symptoms connected with the drug of use is required, especially during the initial engagement with the exercise.
Gender
There are limited data on gender and engagement in exercise programs during SUD recovery. Women were more interested in engaging in a supervised exercise program, according to research by Abrantes et al. (2011), which was part of the same therapeutic setting. Men, on the other hand, showed a preference for unstructured exercise programs that include a variety and alternation of exercise types. Regarding the psychosocial benefits of exercise, women stated that exercise helped them manage stress, stay away from substance use, manage cravings, and improve social interaction with others (Wang, 2019). Another important finding from the research of Abrantes et al. (2011) is that compared to men, women expressed a greater interest in team exercise as opposed to participating in the individual exercise.
Recommendation 1: On the basis of the available literature, it is recommended that females, during their first contact with exercise, participate in supervised and organized group exercise programs, integrated into the same therapeutic environment.
Recommendation 2: Males may participate in exercise programs that include a variety and alternation of types of exercise, according the available literature.
Supervision
It’s important to note that the majority of exercise interventions during SUD recovery were carried out under the supervision of certified sports trainers. This is probably due to the fact that people recovering from SUD may be novice exercisers who fail to apply the exercise protocols appropriately (Buchowski et al., 2011; Weinstock et al., 2017). In light of this, supervised exercise may be beneficial in ensuring that regular and safe exercise is adopted (Linke & Ussher, 2015; Weinstock et al., 2017). Continuing, we must emphasize that including supervised exercise in outpatient therapeutic programs enables its implementation in a controlled environment, enhancing researchers’ capacity to assess its effectiveness (Linke & Ussher, 2015).
Recommendation 1: Supervised exercise is recommended, as proper implementation and, consequently, safety can be ensured, conditions that may lead to the gradual adoption of the exercise.
Safety
Individuals undergoing SUD recovery, especially during the early-stage treatment, have poor health and low fitness as a result of chronic use of both legal and illegal substances. Consulting a physician is essential to ensure safety and to ensure monitoring for any current or past health problems (Weinstock et al., 2012; Weinstock et al., 2017). It is easy to conclude that these individuals, due to their poor physical condition, are often excluded from studies related to exercise implementation or easily drop out (Weinstock et al., 2012).
Recommendation 1: A thorough pre-participation check-up and doctor clearance are recommended.
Exercise adherence
Despite the well-known benefits of exercise on the brain’s reward circuits, engaging individuals with SUD in exercise programs is a difficult and challenging procedure, with dropout rates exceeding 50%. (Weinstock et al., 2012; Muller & Clausen, 2015). Poor social support for exercise, low self-efficacy, lack of time, low motivation to exercise, and intensive exercise, which, when combined with poor initial physical condition, act as barriers to retention in exercise programs (Muller & Clausen, 2015; Weinstock et al., 2012). In addition, some exercise programs do not provide sufficient time engagement with exercise so that the individual can benefit from its benefits (Weinstock et al., 2012). Furthermore, individuals with SUD frequently report financial difficulties that prevent them from purchasing exercise equipment or participating in exercise programs (Muller & Clausen, 2015).
On the contrary, there are several factors involved in successfully starting and maintaining an exercise program. Social support, increased self-efficacy, appropriate physical activity choices, goal setting, behavioural contracts, positive reinforcement, and feedback are all important factors in enhancing adherence to an exercise program (Muller & Clausen, 2015; Weinstock et al., 2012). As stated previously, moderate-intensity exercise has a higher rate of adherence than intense exercise (Abrantes et al., 2011; Abrantes & Blevins, 2019).
Recommendation 1: It is recommended that exercise programmes be suitably developed and adapted to account for the above factors and propose solutions to address them.
Motivation
Long-term substance abuse may have disrupted reward circuits, making pleasure and good feelings harder to experience in the early stages of abstinence (Huhn et al., 2016). Furthermore, poor health or physical disabilities are often mentioned as barriers to exercise, which should be taken into account when exercising or increasing physical activity is recommended in this population (Caviness et al., 2013). In addition, the high rates of coexisting mental disorders, which characterize this population, negatively affect the motivation to drop out of exercise (Abrantes & Blevins, 2019). Thus, the lack of motivation and encouragement was identified as one of the most significant perceived barriers to exercise for individuals with SUD (Abrantes et al., 2011; Panagiotounis et al., 2022d; Muller & Clausen, 2015). However, there is a lack of exercise interventions that include behaviour change strategies and motivation enhancement. Techniques such as self-monitoring, goal setting, and the provision of choice are some of the teachings that have been used (Linke & Ussher, 2015). Also, pedometers and other portable devices that monitor physical activity, as well as financial incentives, have been tested in exercise interventions in populations with SUD (Linke & Ussher, 2015; Weinstock et al., 2008).
Utilizing goal setting to enhance self-confidence, autonomy, and relationships with others is a key strategy that can enhance the motivation of individuals with SUD to change behaviour. The provision of choice of sports and exercise activities; the setting of new challenging goals, based on the successful completion of previous goals; continuous feedback; and the self-monitoring of performance are structural elements that can lead to the enhancement of positive behaviour change. In addition, the use of support from both peers (at a team level) and the trainers creates favourable conditions that enhance the effectiveness of promoting the desired behaviours.
Individuals living with SUD can be trained in strategies to enhance behavioural change and then transfer them to SUD recovery and other aspects of their lives by participating in exercise and sports programs.
Recommendation 1: In this context, the use of strategies and techniques for motivation and behaviour change is recommended.
Recovery setting
Regarding the recovery setting, it seems that exercise interventions are better implemented and show greater adherence in inpatient recovery settings compared to outpatient (Abrantes & Blevins, 2019; Sarkar & Varshney, 2017). Possible factors influencing this process appear to be direct access to substances, direct monitoring and supervision, as well as easy access to facilities (Abrantes & Blevins, 2019; Williams & Strean, 2004; More et al., 2017).
Recommendation 1: To enhance participation, guidance and supervision are recommended as well as facilitating easy access to exercise facilities.
Future Research
Recommendation 1: Since behavioural therapies and medication, or a mix of the two, are utilized in the SUD recovery, further study is needed to see how exercise interacts with these therapies.
Recommendation 2: Since the reward systems that define both addiction and exercise have similar processes (behavioural, cognitive, and physiological mechanisms), it is recommended that future studies include data reported by all of the aforementioned mechanisms.
Recommendation 3: Further research on the design, implementation, and evaluation of exercise programs tailored to each stage of SUD recovery is recommended.
Recommendation 4: It is recommended that research be conducted that examines not only the short-term benefits of exercise but also its long-term benefits for the target group.
Recommendation 5: Gender, drug of abuse, co-morbidity, and recovery setting all suggest more research into the needs of different subgroups.
Recommendation 6: Further investigation of the effect of exercise on other aspects of the lives of individuals living with SUD is recommended, such as employability, education, and the development of social networks.
Recommendation 7: It is recommended to investigate the relationship between SUD and exercise addiction and how it can develop during treatment
Recommendation 8: Further research on the motivation processes of individuals with SUD, as well as the barriers and facilitators that lead to their initial and long-term exercise engagement, is required.
Recommendation 9: Further research on the perceptions and attitudes of adolescents and young adults with SUD toward exercise, as well as the outcomes of their engagement, is required.
Recommendation 10: To identify the cost-effectiveness of exercise interventions in the SUD treatment, further research is required.
Strengths and limitations
The following recommendations are the result of a review of the relevant literature on an international and national level, as well as research that has been conducted in the field, as well as the author’s own experience, which was gradually formed by his active engagement in the field of SUD recovery. The implementation of co-financed projects from the European Erasmus+ Sport program, which provided the opportunity for more research into the effects of exercise on the target population, was also a significant contribution. However, given the limited published research data in the area, it is advised that the recommendations be adopted with caution.
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