PACE Yourself: Alcohol, Addiction and Exercise

By Megan Johnson Mccullough

PACE Yourself: Alcohol, Addiction and Exercise provides qualitative research about the influence of exercise on alcohol use disorder (AUD) recovery. In addition, the author explains how someone can benefit from exercise and explores how the PACE method could help keep new addictions at bay. PACE is an acronym for Proactive Awareness Controlling Excess. The author has developed an app of the same name which is available in the Apple store. Exercise is medicine when it comes to the recovering body and mind of an alcoholic. Physiological and psychological changes as a result of moving the body contribute to prolonged sobriety and deter the cyclical threat the nature of alcohol abuse can pose upon person in recovery.

The struggle to never become powerless to alcohol again can be kept at bay when the benefits of exercise over power the benefits alcohol used to have. However, the addictive mind can find a new habit to replace the old one. The PACE method proposes steps to become aware of replacement type behaviors with the understanding that anyone can become addicted to anything.

• Provides information about, and for, persons suffering from alcohol use disorder (AUD)
• Introduces exercise as a recovery tool in overcoming alcohol addiction
• Discusses exercise addiction and alcohol addiction together to shed light on a new recovery method from the perspective of real participants suffering from AUD

• Language: English
• Publisher: Academic Press
• Release date: Mar 29, 2023
• ISBN: 9780443133527

Megan Johnson Mccullough

Megan Johnson McCullough is a Doctor of Health and Human Performance and owner of Every BODY’s Fit in Oceanside, CA. She is an elite NASM Master Trainer and professional natural bodybuilder. Dr. McCullough is certified from the National Academy of Sports Medicine (NASM) and the National Exercise & Sports Trainers Association (NESTA). She is also a certified Group Exercise Instructor by the Aerobics and Fitness Association of America (AFAA), as well as being certified in Aqua, Cycle, Yoga, and Zumba. Megan also holds titles of Corrective Exercise Specialist, Drug & Alcohol Recovery Fitness Specialist, Fitness Nutrition Specialist and Senior Fitness Specialist. Megan is a Wellness Coach as well as a Lifestyle and Weight Management Specialist. She is a world champion natural bodybuilder, fitness model and author of 6 books. Dr. MuCullough also has a strong social media presence with over 30K Instagram followers.

Book preview

PACE Yourself

Alcohol, Addiction and Exercise

Megan Johnson Mccullough, EdD

NASM Master Trainer and Owner of Every BODY’s Fit

Table of Contents

Cover image

Title page

Copyright

Dedication

Preface

Acknowledgments

Chapter 1. Introduction to the study

Background

Problem statement and significance of the study

Theoretical foundation

Researcher's positionality

Purpose of the study

Qualitative research questions

Research methodology

Setting and sample

Definition of terms

Summary

Chapter 2. Literature review

Background

Transtheoretical model

Relapse and dropout rates

Review of literature

Physiological effects of exercise on persons with AUD

Gap in literature

Application of transtheoretical model

Conclusion

Chapter 3. Methodology

Problem statement

Research questions

Research methodology

Research design

Study population and sample selection

Sources of data

Trustworthiness of the study

Data collection procedures

Data analysis procedures

Step one

Step two

Ethical considerations

Limitations

Summary

Chapter 4. Data analysis and findings

Themes

Exercise recommendation

Utilization of exercise

Accountability and support

Motivational effects

Substitution benefits

Better life without alcohol

Summary

Chapter 5. Discussion and conclusion

Discussion and interpretation

Ten processes of change

Dramatic relief

Self-reevaluation

Environmental reevaluation

Social liberation

Self-liberation

Helping relationships

Counter conditioning

Reinforcement management

Stimulus control

Implications for practice and recommendations for future research

Conclusion

Chapter 6. PACE Method

Mindset of addiction

Addiction begins

Exercise addiction

Replacement addiction

PACE Method

References

Appendices

Index

Copyright

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Dedication

In loving memory of my mother, Rebecca Fern Johnson, October 09, 1952–August 12, 2008.

Preface

Alcohol use disorder (AUD) continues to be one of the leading causes of preventable death in the U.S. (SAMHSA, 2018) with a small percentage of persons with AUD seeking treatment (NIH, 2020) and most of the treatment-seeking population troubled by relapse (Sureshkuma, 2017). There is not a one-size-fits-all strategic approach to AUD recovery, which continues to challenge the medical addiction-related community. The promising effects of exercise for AUD recovery have been shown including both psychological and physiological variables. Quantitative exercise-based researchers have shown improvements in mood, reduction in anxiety and withdrawal symptoms, as well as reductions in cravings and number of drinking days. However, the threat of relapse remains due to the chronic cyclical nature of addiction-related behaviors.

A person seeking recovery for AUD mirrors the six stages of the transtheoretical model of behavior change (TTM). The goal for recovery is to progress through these stages until termination is reached, all while avoiding relapse. There remains little, if any, qualitative research from the perspective of AUD recovery participants regarding the influence of exercise on alcohol abstinence. Using a basic qualitative study, I investigated this gap using interviews and exercise journal data collection to share the stories and experiences of 11 participants in AUD recovery who are currently using exercise as part of their comprehensive treatment program. Data were analyzed to develop themes centering upon the ten processes of change, which conveyed the positive influence of exercise on the participants' AUD recovery process, particularly upon swaying decisional balance.

From the findings of this qualitative research, I developed the PACE Method to counteract the possible replacement of alcohol use with exercise addiction. Participants of my study suggested the benefits of exercise for AUD recovery as a positive tool, but exercise cannot serve as a replacement, nor should exercise be the sole modality of treatment. The PACE Method stands for proactive aware controlling excess which can be applied to appropriately incorporate exercise as medicine with the correct prescription, i.e. dose. I have also developed the Fit PACE cell phone application as a tangible tool for persons in recovery to help assist with accountability, moderation, and sustainability of exercise as a healthy lifestyle choice during the maintenance and termination stages of recovery. Fit PACE serves as a strategic tool to be recommended/referred to by medical and fitness professionals for patients/clients to use as part of a comprehensive recovery/treatment program. Furthermore, I have recently become one of U.S.'s first MedFit Care providers which means under the scope of my practice as a Drug and Alcohol Recovery Fitness Specialist, I can now take Health Savings Accounts (HSA) and Flexible Spending Accounts (FSA) for payment of fitness services. My personal training can be included as a medical expense on income taxes. As my study has shown, exercise does qualify as a necessary prescription and this groundbreaking opportunity is now available for persons in recovery.

Dr. Megan Johnson McCullough, EdD

Drug and Alcohol Recovery Fitness Specialist

Spread Your Wings

Acknowledgments

The production of this book has been the culmination of what I believe God's path has led me towards. From a childhood traumatic experience, life of sports, exercise and bodybuilding, to owning a fitness studio, to completing my research for my doctorate…… the pieces Fit together. I have been nothing short of blessed with a team of incredible people in my life. I would like to acknowledge my husband, Carl's, unwavering support and love. I'm also grateful for my father, Ray Johnson, for being my voice of reason and to my own coach, Lorenzo Gaspar, who is a mentor and avid positive influence in my life. A special thank you to the participants of my study, as well as those who have been part of my educational journey, especially Dr. Ayanna Walker, Ph.D. Thank you to the staff and production team at Elsevier who made this dream come true.

Chapter 1: Introduction to the study

Abstract

The National Institute on Alcohol Abuse and Alcoholism (2021) defines alcohol use disorder (AUD) as a chronic brain disorder involving compulsive drinking, loss of control for alcohol use, and negative emotions when the person is not drinking. Relapse rates remain as high as 40%–60%, highlighting the need to better understand how to reach this population and how exercise can be an influential tool for alcohol abstinence (Sureshkuma, 2017). Research has shown promising effects of exercise to treat AUD based on quantitative-based exercise interventions (Hechanova et al., 2017). Manthou et al. (2016) identified 10 studies showing the positive effects of exercise on alcohol related outcomes. Studies have lacked the application of a qualitative lens exploring how and why exercise is a behavior change associated with alcohol abstinence. The current qualitative study used the transtheoretical model of behavior change to explore the experiences of AUD recovery participants using exercise in their comprehensive treatment program.

Keyword

Alcohol use disorder (AUD); Diagnostic and statistical manual of mental health disorders (DSM-5); Exercise; Exercise is medicine (EIM); Motivation; Physical activity; Qualitative; Recovery; Self-efficacy; Transtheoretical model of behavior change (TTM)

The effects of exercise on alcohol abstinence may render useful both psychologically and physiologically in the treatment of alcohol use disorder (AUD). Exercise has beneficial effects on mood, depression, anxiety, self-efficacy, and self-perception (Ekkekakis & Petruzzello, 1999; Hughes, 1984; Manthou et al., 2016; Read & Brown, 2003). Physiologically, exercise can attenuate the effects of alcohol consumption at the cellular level shown by the decline in hepatic mitochondria, extending oxidative damage in the body, and improvement in decreased capillarization in skeletal muscle (ElSayed & ElSayed, 2005). There are several stages for AUD treatment, including detoxifying, restoring function and evaluation, maintaining patient's care, and monitoring for recurrence (Institute of Medicine, 1990). Exercise can serve as part of this therapeutic treatment model for alcohol abstinence, specifically the recovery stage.

There are promising effects of exercise to treat AUD (Hechanova et al., 2017). Previous researchers have focused on quantitative-based exercise interventions producing measurable alcohol related outcomes. However, a qualitative lens exploring how and why exercise is a behavior change associated with alcohol abstinence is missing. The motivating research question of this study explores how participants in AUD recovery understand the influence of exercise performance upon alcohol abstinence. With respect to this inquiry and reaching the AUD population, this topic is of particular interest to me because of my profession as a Certified Personal Trainer (CPT) and Drug and Alcohol Recovery Fitness Specialist. Moreover, I am the daughter of a deceased alcoholic mother.

Background

The National Institute on Alcohol Abuse and Alcoholism (2021) defined AUD as a chronic brain disorder that involves compulsive drinking, loss of control for alcohol use, and negative emotions when the person is not drinking. According to the Diagnostic and Statistical Manuel of Mental Health Disorders (DSM-5) AUD can be classified as mild, moderate, or severe. Regardless of classification, recovery is possible. Unfortunately, the National Survey on Drug Use and Health (NSDU, 2019) reported only 7.3% of adults ages 18 years and older who have AUD (6.9% of males and 7.9% of females) received treatment in the past year for AUD.

The three main forms of treatment for AUD include behavioral treatments, medications, and mutual-support groups. Evidence has shown the positive effects exercise performance has on excessive alcohol use. Manthou et al. (2016) identified 10 studies pertaining to the effects of exercise on alcohol related outcomes. Six of these studies reported exercise having a positive impact on alcohol consumption, the urge to drink, as well as abstinence rates (Brown et al., 2009, 2014; Murphy et al., 1986; Sinyor et al., 1982; Ussher et al., 2004; Vedamurthachar et al., 2006). Three of the sets of authors concluded exercise response in persons with AUD are different compared to healthy individuals (Coiro et al., 2007; Georgakouli et al., 2015; Jamurtas et al., 2014). Jamurtas et al. reported the effects of exercise on endogenous opioids, which influence the urge to drink.

There is certainly existing evidence explaining how exercise positively affects excessive alcohol use. Studies have explored exercise as an adjunctive treatment for AUD focusing on using exercise to achieve a pleasurable state without drinking, by improving mood, increasing self-efficacy, providing group and social support, providing a nondrinking alternative, decreasing stress reactivity, and improving coping (Read & Brown, 2003). However, there are challenges in providing efficacious, individualized treatment plans and outcomes for AUD patients according to their readiness to change (Bottlander et al., 2006). The current study used the transtheoretical model (TTM) of behavior change as a guiding tool for the basic qualitative research. Future studies are needed to strengthen the case for using exercise as medicine. To date, qualitative research is missing which could connect how and why exercise produces beneficial outcomes for AUD recovery. The voices and stories of the AUD recovery exercise participants of this study can connect previous quantitative research to new qualitative information, which can modify and improve AUD recovery treatment prescription and strategies.

Problem statement and significance of the study

AUD is a chronic brain disease that threatens to remain a cyclical pattern of addiction for 14.4 million Americans (NIH, n.d). Despite the availability of current treatment options, relapse rates remain as high as 40%–60% (Sureshkumar et al., 2017). Researchers have shown the benefits of exercise as an adjunctive therapy to AUD treatment, but dropout rates have been high (Hallgren et al., 2016; Roessler et al., 2017) motivational support has been missing, and exercise plans have lacked individuality (Mamen et al., 2011). This general attempt to use exercise as a complementary treatment has not addressed how and why participants are influenced by exercise to help them abstain from alcohol use. Understanding the connection to behavior change is necessary for lasting recovery. Exercise is medicine, but the dose and prescription must appropriately fit the patient, especially where there is not a one-size-fits-all comprehensive treatment plan for sobriety. Without making the connection to the reasons exercise benefits AUD recovery, participants may not feel motivated to sustain such activity. By understanding the influence of exercise on alcohol abstinence from the participant's perspectives, implicated by the proposed study, improvement strategies from AUD recovery assistance can be better addressed. Using this qualitative approach would combine the expertise of the healthcare community and the fitness professional community to improve community health outcomes affected by the alcohol use barrier.

Theoretical foundation

Because alcohol addiction is a chronic disease, AUD has the potential to revisit a person with AUD for the rest of their life. Seeking and maintaining sobriety depends on the individual's readiness to change, which is part of the TTM. The TTM incorporates Bandura's (1977) theory of self-efficacy, which has been shown by the increase in self-confidence and self-esteem resulting from exercise performance. Regarding AUD recovery, exercise becomes a coping mechanism to deter from alcohol use (Bandura, 1977). Exercise has also been shown to reduce stress which in turn, can reduce the desire to drink alcohol (Monti et al., 1995). Exercise can improve mood, depression, and anxiety (Ekkekakis & Petruzzello, 1999; Hughes, 1984; Read & Brown, 2003). All these factors affect which of the six stages of TTM the participant might currently be experiencing when seeking recovery (precontemplation, contemplation, preparation, action, maintenance, termination) (ACSM, 2010). Because relapse rates remain as high as 40%–60%, there is a need to better understand how to reach this population and how exercise can be an influential tool for alcohol abstinence (Sureshkuma, 2017).

Researcher's positionality

Having experienced a traumatic event finding my very own mother deceased on the bathroom floor from her bout with AUD, I am very familiar with the chronic cycle a person faces ongoing with alcohol use. As the 12 steps of Alcoholics Anonymous (AA) states, individuals admit they have become powerless to alcohol (American Addiction Centers, 2021). Exercise can be that missing tool to give someone the very power they need to stay sober longer. Not every form of therapy is meant for every AUD victim, which is why the more evidence-based strategic options for recovery, the wider audience healthcare and fitness professionals can reach.

All these options, exercise included, should include qualitative information that addresses the complexity of addiction related behaviors. The power to change comes from within the participant but recognizing how one can best reach their readiness for lasting change, is the challenge the public health system will forever face. One more option can save one more life, which is statistically significant to that person's family and loved ones. The current study sought to serve a community suffering from AUD from an unbiased stance, with an open ear and mind during the sharing of their stories through interview format and an exercise journal.

Purpose of the study

The purpose of this study was to explore the experiences of AUD recovery participants using exercise as part of their comprehensive treatment program. The qualitative findings of this study investigated AUD recovery participant's perspectives who are using exercise as a type of medicine to sustain sobriety (Hechenova et al., 2017). A personalized approach to behavior change (exercise) that aligns with one's values, beliefs, goals, socioeconomic circumstances, emotional state, and environmental context is a motivational, personalized approach to treatment for AUD (Lachman et al., 2018). The aim of this study investigated how AUD recovery participants are implementing exercise into their daily lifestyle to abstain from alcohol use. Interventions for heavy drinking that do not stigmatize or require an individual to see a mental health professional may increase the utility and acceptability of the intervention and ultimately increase the number of individuals effectively treated (Leasure et al., 2015; Weinstock, 2010). The advocacy for exercise as an adjunctive therapy for AUD treatment exists, but to maintain sobriety, actual AUD recovery participants need to make the connection to how and why exercise helps their recovery. Motivation through this connection is a key determinant for sustainability to offset revisiting previous stages of the TTM.

Alcohol use disorder is characterized as a chronic disease. Hechanova et al. (2017) stated that patients at risk for chronic diseases should have physical activity (PA) included as part of their management plan. Exercise can serve as a vaccine that lowers the risk for chronic diseases (relapse as well) and improve the quality of life (U.S. Department of Health and Human Services, 2017). In 2008, the American College of Sports Medicine (ACSM) created the Exercise is Medicine (EIM) initiative to encourage the prescription of exercise by primary care providers as part of the treatment plan for their patients. Exercise can be used as a highly effective drug when prescribed in the right dose (ACSM, 2017). Because not all AUD recovery participants can be considered in a homogenous group, the more tools available to reach a wider audience of persons in recovery, the better the chance to reduce relapse rates (Bushman, 2018). Adding qualitative information to the field of AUD recovery can strengthen the stance that exercise is medicine, enhance quantitative studies, and help improve AUD recovery outcomes.

Qualitative research questions

Central Research Question: How do participants in AUD recovery understand the influence of exercise performance upon alcohol abstinence?

Sub-question 1: According to participants in AUD recovery who have performed exercise as part of their recovery program, how does exercise impact their desire, urge, and/or cravings for alcohol?

Sub-question 2: According to participants in AUD recovery who have performed exercise as part of their recovery program, what physical and mental effects of exercise might impact them from using alcohol?

Research methodology

The study's focus centered upon AUD recovery participant's perspectives pertaining to the influence of exercise on alcohol abstinence. Using a basic qualitative research study, data were collected from one-on-one in person or Zoom interviews with each participant as well as a 3-week exercise journal completed by each participant. The one-one-one interviews were conducted either in-person or over Zoom depending on the participant's preference. The purpose of this data was to develop themes which described participant's relationship to exercise in their recovery. I performed thematic analysis of this data, specifically by using coding to report findings according to participant's responses. In doing so, this data collection procedure used triangulation. Member checking was included in the data collection process as well to ensure all data had been documented accurately. Appendices A and B include the script and questions for the one-on-one interview and the questions and template for the exercise journals. The interview recordings were transcribed for the coding schema process. All data collection and analysis used for this basic qualitative data are included as the Appendices of the report, which create an audit trail for readers to clearly follow how final themes were developed. Transparency of analysis is evident from details indicating how the codes were developed, making results transferable for readers (Bloomberg & Volpe, 2012).

Setting and sample

Using a network known to myself, purposeful sampling took place by advertising via the use of a flyer on Facebook alcohol recovery related network sites and my business Facebook page (Every BODY's Fit) as well as my exercise-related business Instagram account (@megan_everybodysfit). I requested any persons interested to directly message (DM) me for more information. The first 9–12 participants who meet all inclusion criteria were selected.

The current basic qualitative study performed included 11 volunteers who were over the age of 18 and considered in recovery for AUD in the sustained (1–5 years) or stable (greater than 5 years) time-frames of sobriety, must be currently performing any type of exercise modality (planned and structured) for a minimum of 40 min at least one time per week, be available to partake in the one-on-one in person or Zoom meeting lasting up to 60 min, and be able to complete a 3-week exercise journal detailing their exercise habits. Exclusion criteria were that the participant was not in the sustained or stable classifications for recovery, and/or not exercising (planned and structured) at least one time per week for at least 40 min, and/or has/had a drug related addiction.

Definition of terms

Alcohol use disorder (AUD): Can be classified as mild (two to three symptoms) moderate (four to five symptoms) or severe (6 or more symptoms). Symptoms include the following signs: (1) being unable to limit the amount of alcohol the person drinks; (2) wanting to cut down on the amount of alcohol consumed but attempts have been unsuccessful, spending a lot of time drinking, getting the alcohol, and recovering from alcohol use; (3) cravings or urges to drink; (4) alcohol use interfering with work, school, or home obligations; (4) continued alcohol use despite having interpersonal or social problems; (5) giving up once important social, occupational, or recreational activities; (6) reoccurring use of alcohol in potentially physically dangerous situations; (7) continuing to use alcohol despite persistent or recurrent physical or psychological problems it has cause; (8) tolerance; and/or (9) withdrawal (American Psychiatric Associations, Diagnostic and Statistical Manual of Mental Disorders DSM-5; National Institutes of Health, 2021).

Decisional Balance: The perceived positive aspects (pros, advantages) and negative aspects (cons, disadvantages) that are associated with behavior change (Liu et al., 2020).

Exercise: This describes PA that is planned, structured, and repetitive. Movement has an objective to improve or maintain physical fitness (Casperson et al., 1985).

Motivation: A function of one's expectation of success and perceived value. Perception governs motivational beliefs including success (goals, self-concept, task difficulty) task value, social influences (parents, teacher or peer pressure, professional values) and environment (Cook & Artino, 2016).

Physical Activity: This describes any bodily movement produced by the skeletal muscles, resulting in energy expenditure. Examples include household, sports, occupational, or other movements associated with daily living activities (Casperson et al., 1985).

Recovery: This is the process an individual pursues to reach remission from AUD. According to DSM-5 criteria, remission from AUD requires the individual not meet any criteria associated with AUD, except for cravings. Classification of remission is based upon duration, defined by the following: initial (up to 3 months) early (3 months–1 year) sustained (1–5 years) and stable (greater than 5 years) (National Institutes of Health, n.d.).

Self-efficacy: A person's beliefs or expectations in their ability to perform the tasks necessary to attain a valued goal (Maddux et al., 2018).

Summary

In this chapter introduced the basic qualitative study performed, which developed themes based upon the commonalities among the voluntary 11 AUD participant's experiences performing exercise as part of their recovery process. Although existing research provides evidence that exercise can positively affect the deterrence, frequency, and abstinence of alcohol use, qualitative data is missing pertaining to participant's understanding of how and why exercise is or is not helping their progression through the TTM stages. Chapter 2 will include a literature review of existing current research which supports the use of exercise as an adjunctive therapy for AUD. Chapter 2 also identifies the gaps and limitations of these studies, particularly noting missing qualitative research pertaining to the influence of exercise upon AUD recovery from participant's perspectives. Chapter 3 will entail the methodology, population studied, research design and analysis, trustworthiness, ethical considerations, and limitations of the study. Chapter 4 is a detailed analysis of the study's data to include coding and transcription of participant's interviews. Finally, Chapter 5 will discuss the findings and interpret what this data means in relation to the dissertation topic.

Chapter 2: Literature review

Abstract

Only 7.9% of the 14.4 million adults diagnosed with AUD seek treatment (NIH, 2020). A standardized treatment doesn't exist because there is not a one-size-fits-all approach that guarantees sobriety. The lack of a standardized approach creates a challenge for designing effective and strategic treatment options (NIH, 2020). Rese archers have focused on group exercise interventions or individually performed exercise for AUD treatment, but have not specifically investigated qualitative components, therefore, the literature review points out gaps within exercise-based AUD interventions. Topics included in the literature review findings include effects of exercise on mental health such as mitigating alcohol cravings as well as effects of exercise on physiological components.

Keywords

Behavioral treatment; Cravings; Diagnostic and Statistical manual of mental health disorders (DSM-5) criteria; Exercise prescription; Gap in literature; Pharmacological treatment; Relapse; Support groups; Transtheoretical model of behavior change (TTM) stages

There has been a growing interest in research pertaining to the role of exercise for the treatment of substance abuse disorders (SUDs). According to the Office of Disease Prevention and Health Promotion (n.d.)which is part of the U.S. Department of Health and Human Services, one of the goals of Healthy People 2030 is to reduce drug and alcohol addiction. The goal of reduction is critically needed for the nearly 20 million people in the U.S. who have a SUD, especially for the majority who do not get treatment (Substance Abuse and Mental Health Services Administration, 2014). Furthermore, Healthy People 2030's addiction objectives include the following: increase the proportion of people with a substance abuse disorder who go treatment in the last year (SU-01) and reduce the proportion of people who had alcohol use disorder (AUD) in the past year (SU-13).

Exercise can be utilized as a healthy and rewarding alternative behavior to alcohol use (Linke & Ussher, 2015). Not only are there a broad range of health benefits (Haskell et al., 2007; Hillman et al., 2008; Martin et al., 2009; Nelson et al., 2007) but exercise also enhances one's mood (Blumenthal et al., 2007; Daley, 2008; Dunn et al., 2005; Rethorst et al., 2009; Sparling et al., 2003; Trivedi et al., 2006) can reduce symptoms of anxiety (Abrantes et al., 2009; Breus & O'Connor, 1998; Wipfli et al., 2008) and can reduce the distress of withdrawal (Buchowski et al., 2011; Smith et al., 2008; Taylor et al., 2007; Ussher et al., 2004; Williams et al., 2011). These health benefits associated with exercise can be applied to a person seeking treatment for AUD to assist in their recovery process. Recovery entails much more than abstaining from alcohol. Individuals must work to change their lives; otherwise, all the existing factors that contributed to alcohol use will still be there. The threat of relapse will always remain. Relapse can be a gradual process beginning weeks or months leading up to when a person drinks again. It is important for individuals to practice self-care (to include exercise) to offset and prevent feelings of being uncomfortable in one's own skin. When uncomfortable feelings surface (e.g., anxiety, stress, depression, anger), it is likely the person will look for ways to escape, relax, and reward themselves (i.e., drink alcohol) (Melemis, 2015).

Alcohol use is the third leading cause of preventable death in the United States with 14.4 million adults ages 18 and older have been diagnosed with AUD (SAMHSA, 2018). In the past year, 25.1% of adults ages 18 and older have had at least one heavy drinking day, which equates to five or more drinks for men and four or more drinks for women (CDC, 2021). AUD is a brain disease characterized by the inability to stop or control alcohol use despite the adverse consequences (NIH, 2021). Only 7.9% of the 14.4 million adults diagnosed with AUD seek treatment and, for those who attend treatment, there is not a one-size-fits-all approach that guarantees sobriety. The lack of a standardized approach creates a challenge for designing effective and strategic treatment options (NIH, 2021). Roessler et al. (2017) discussed the challenges of AUD treatment including the lack of social stability and support, lack of support from one's social network of non-drinkers, being disengaged with treatment, attempts at multiple treatments, young age, personality disorder, cognitive deficiencies, and low alliance (lack of trust or vision with treatment source) (Brorson et al., 2013; O'Flynn, 2011; Weisner et al., 2003).

In accordance with the American College of Sports Medicine's (ACSM) Exercise is Medicine (EIM) initiative, exercise has been shown to have promising effects in the treatment of AUD (Hechanova et al., 2017). Previous researchers have focused on group exercise interventions or individually performed exercise for AUD treatment (Brown et al., 2009, 2014; Coiro et al., 2007; Donaghy, 1997; Georgakouli et al., 2015; Jamurtas et al., 2014; Sinyor et al., 1982; Ussher et al., 2004; Vedamurthachar et al., 2006). Each of these interventions have attributed group and individual exercise having positive influences upon persons with AUD via psychologically and physiologically induced outcomes (Hallgren et al., 2017; Mandolesi et al., 2018). However, these interventions have not specifically investigated qualitative components related to the influence of exercise on alcohol abstinence. The purpose of this literature review is to explore existing research pertaining to the psychological and physiological benefits of exercise among persons seeking alcohol abuse treatment. The literature review will also highlight the gaps within exercise-based AUD interventions, particularly focusing on missing qualitative information.

Background

Alcohol use disorder (AUD)

An estimated 15 million adults ages 18 and over have AUD (NIH, n.d.). A medical diagnosis of AUD entails a chronic relapsing brain disorder with an impaired ability to stop or control using alcohol despite consequences. The Diagnostic and Statistical Manual of Mental Health Disorders (DSM-5) defines AUD based upon 11 criteria (Fig. 2.1). These are questions which evaluate alcohol use and one's relationship to alcohol. For diagnosis of AUD, a person must meet two or more of the 11 criteria within the same 12 months (NIH, n.d.). There are also different levels of AUD severity which are as follows (NIH, n.d.): mild, having two to three of the 11 symptoms; moderate, having four to five of the 11 symptoms; and, severe, having six or more of the 11 symptoms.

Figure 2.1  DSM-5 alcohol use disorder criteria.  Note. Adapted from Winslow, B., Onysko, M., & Hebert, M. (2016). Medications for alcohol use disorder. American Family Physician, 93(6), 457–465. Copyright 2013 by the American Psychological Association.

Alcohol misuse results in 88,000 deaths each year. According to the National Institutes of Alcohol Abuse and Alcoholism (NIAAA), the associated healthcare expenses, crimes, property damage, and lost workplace productivity from alcohol misuse costs the U.S. $249 billion per year (NIH, n.d.). Because of these alcohol misuse related consequences, part of the Strategic Plan 2017–21 by the National Institute on Alcohol Abuse and Alcoholism (Goal 4) is to develop and improve treatments for alcohol misuse, AUD, co-occurring conditions, and alcohol-related consequences (NIH, n.d.).

Main forms of treatment

The three main forms of treatment for AUD include behavioral treatments, medications, and mutual-support groups. The use of these traditional forms of treatments has not had entirely desirable outcomes because relapse rates remain high, pharmacology can have unwanted side effects, and remission rates vary between 60% and 90% (Hallgren et al., 2016; Maisto et al., 2000; Miller et al., 2001). The more treatment options available, the more opportunity the individual connects with the coping skills to adhere from alcohol use and improve these treatment outcomes. In addition to any combination of these treatments, exercise could be a complimentary lifestyle change as part of the individual's recovery strategy.

Ray et al. (2020) classified combined behavioral and pharmacological interventions as best practices for addiction. These findings suggest best practices in addiction treatment should include pharmacotherapy plus cognitive behavioral therapy (CBT) or another evidence-based therapy. Exercise could be part of this strategy. Ray et al. reported a sample of 62 effect sizes from 30 randomized trials that studied CBT with some form of pharmacotherapy for AUD or SUDs. Of this sample, 15 (50%) of the substances targeted were alcohol.