1. Introduction

Substance Use Disorders (SUDs) represent a critical challenge in global public health, with far-reaching consequences for individuals, families, and societies. According to Volkow and Blanco [1], SUDs are characterized by chronic, relapsing patterns of compulsive substance use, often accompanied by significant impairments in physical, psychological, and social functioning [1]. The World Health Organization (WHO) highlights that the global burden of SUDs continues to grow, exacerbating healthcare costs, disability rates, and socioeconomic disparities worldwide [2].

While traditional treatment approaches, including pharmacotherapy and psychotherapy, have proven effective for many, they often fail to address all facets of SUDs, particularly the integration of physical and behavioral health. Relapse rates remain a significant concern, underscoring the need for innovative and holistic interventions that support long-term recovery [3]. Recent advancements in understanding the neurobiological and psychosocial aspects of SUDs have prompted interest in complementary therapies, such as physical activity (PA), as part of a broader treatment strategy.

PA offers a multifaceted approach to recovery, targeting both neurobiological and behavioral pathways. Evidence shows that regular PA enhances neuroplasticity and modulates the brain’s reward system, which is often dysregulated in individuals with SUDs [4]. The literature proposes that exercise can act as a novel treatment for drug addiction by alleviating withdrawal symptoms, reducing cravings, and improving mood through its effects on dopamine regulation and brain-derived neurotrophic factor (BDNF) [4]. Furthermore, studies suggest that PA positively impacts anxiety and depression, which frequently co-occur with SUDs, thereby addressing critical comorbidities that hinder recovery [5,6]. Notably, Giménez-Meseguer et al. reported that exercise tailored to the needs of individuals with SUDs significantly improved their physical health, mood, and psychological well-being, thus highlighting its relevance as a holistic therapeutic tool [7]. Animal studies have also provided insights into the mechanisms underlying PA’s benefits. For example, research on morphine-dependent and ethanol-withdrawn rats demonstrates that voluntary exercise can mitigate anxiety and seizure susceptibility, highlighting the neuroprotective role of PA in addiction recovery [6,8]. These findings provide a foundation for exploring how PA interventions can complement existing treatments and offer new avenues for addressing the complexities of SUDs.

This review aims to evaluate evidence supporting PA as an adjunctive therapy for SUDs, focusing on its neurobiological mechanisms, therapeutic benefits, and practical implications for clinical and community settings. By examining the interplay of physical, psychological, and social factors, this review seeks to advance the understanding of PA’s role in promoting recovery and long-term well-being for individuals with SUDs.

The review is structured as follows: first, we examine the neurobiological mechanisms through which PA benefits individuals with SUDs. Next, we discuss specific PA interventions and their efficacy in different contexts. Finally, we analyze barriers to implementation and offer recommendations for integrating PA into clinical and community settings.

2. Results

A total of 50 studies met the inclusion criteria and were included in the final review. Results were grouped thematically (Table 1) and further comprehensively discussed, focusing on barriers and strategies for enhancing adherence to PA and future research.

2.1. Neurobiological Mechanisms and Brain Plasticity

The beneficial effects of PA on SUDs are supported by neurobiological mechanisms involving dopamine and brain-derived neurotrophic factor (BDNF), both crucial for neuronal plasticity [9,10,11,12,13]. Lynch et al. [4] hypothesize that PA modulates dopaminergic signaling in the brain, promoting neuronal adaptations that help counter the effects of substances. Physical exercise positively impacts brain circuits associated with reward and pleasure, as demonstrated by Jamurtas et al. [14], who observed increased beta-endorphins and mood improvement in subjects with SUD. Additionally, PA reduces cortisol release, the stress hormone, supporting healthier stress regulation and helping to reduce anxiety, a known relapse trigger [15,16]. Furthermore, the normalization of dopaminergic and glutamatergic activity facilitated by exercise may aid in long-term relapse management [17,18].

An exciting frontier in PA research is the exploration of neurobiological markers that can predict an individual’s response to exercise. Understanding the genetic, epigenetic, and molecular mechanisms that underlie individual differences in exercise-induced neuroplasticity could help personalize PA programs for optimal therapeutic effects. Additionally, neuroimaging techniques such as fMRI could be used to observe real-time changes in brain activity and structure in response to exercise, offering deeper insights into how PA influences brain function in patients with SUDs [19].

2.2. Effects on Abstinence and Craving Symptoms

One of the most studied effects of PA in SUDs concerns its ability to reduce craving and withdrawal symptoms [20,21,22]. The meta-analysis by Wang et al. [15] demonstrated that moderate and intense PA programs can significantly increase abstinence rates, with positive effects also observed on physical and psychological withdrawal symptoms, such as irritability, insomnia, and anxiety. Longitudinal studies indicate that PA contributes to reduced relapse rates both in the early months and beyond, suggesting a lasting impact on maintaining abstinence [23,24].

2.3. Benefits of Mental Health and Quality of Life

PA is associated with significant improvements in mental health and quality of life in SUD patients. Farhana et al. [23] report that PA-based interventions, such as aerobic exercises and yoga, reduce symptoms of depression and anxiety, improve mood, and reduce the likelihood of relapse [25,26,27]. A study by Zhu et al. [28] demonstrated that a group aerobic exercise program improved cognitive functions and emotions in SUD patients.

These effects are attributed to increased levels of endorphins and serotonin, which can enhance emotional well-being [29,30]. Mind-body exercises like Tai Chi have also proven effective in improving emotional regulation, thereby increasing psychological resilience.

2.4. Differences Among Types of Physical Activity and Their Efficacy in SUDs

The type and intensity of PA play a key role in treating SUDs. Aerobic exercises like running and cycling help reduce cravings for stimulants such as cocaine by boosting dopamine and serotonin levels [4,15]. Mind-body activities like yoga and Tai Chi improve emotional regulation and reduce anxiety, making them effective for opioid and alcohol dependencies [31,32]. High-intensity interval training (HIIT) shows potential for neuroplasticity recovery due to increased BDNF levels but requires careful monitoring [4]. A personalized approach that adapts PA to the patient’s needs and recovery stage is essential for optimizing treatment outcomes [33].

3. Discussion

Beyond its physiological effects, PA offers a range of psychological benefits for individuals with SUDs that can be essential in supporting the recovery process. These benefits include increased resilience, enhanced self-efficacy, strengthened emotional regulation, and an overall reduction in stress and anxiety symptoms, all of which play a crucial role in managing and preventing relapse [34,35,36].

Resilience, the ability to cope with difficulties and adapt positively to stressful situations, is an essential aspect for those seeking to overcome addiction. Studies show that PA can help build and strengthen resilience, improving a patient’s ability to face the psychological challenges characteristic of the withdrawal process [34]. This helps patients become more resilient to stressors and develop healthier coping mechanisms than those triggered by substance use [4]. The resilience developed through PA is not merely an immediate effect: long-term studies suggest that as patients continue regular PA, their resilience tends to consolidate [34,37]. This is particularly important for relapse prevention, as resilience helps patients navigate high-risk situations without resorting to destructive behaviors.

PA also contributes to improving self-efficacy, defined as a person’s confidence in their ability to perform specific actions to achieve certain results. PA requires discipline, specific and measurable goals, and progressive performance improvements, all of which strengthen self-confidence [35]. During recovery, patients with a high level of self-efficacy are more likely to believe in their ability to maintain abstinence and face daily challenges without resorting to substance use. PA allows patients to experience tangible progress, such as improvements in endurance or physical strength, which can easily translate into a broader perception of their capabilities, including control over their dependency. Progressive exercise programs, where incremental goals are set and achieved, foster self-efficacy and increase motivation, empowering patients to feel in control of their recovery.

One of the most immediate and well-documented psychological benefits of PA is its ability to reduce anxiety and stress, common and aggravating factors in SUDs. Anxiety can increase relapse risk and often represents one of the primary reasons patients turn back to substances. PA helps reduce cortisol levels and stimulates endorphin release [15]. Mind-body activities like yoga and Tai Chi have proven effective in reducing anxiety levels in SUD patients.

Zhu et al. demonstrated that Tai Chi interventions significantly improved sleep quality and emotional regulation in female patients recovering from amphetamine-type stimulant dependence. These long-term benefits contribute to reduced cravings and relapse risk, emphasizing the importance of incorporating mind-body activities into rehabilitation programs [38].

These activities combine physical movement with breathing and mindfulness techniques, allowing for deep relaxation. These exercises not only improve the patient’s emotional state in the short term but also increase awareness of their emotional responses, promoting more effective stress management.

PA can also enhance emotional regulation, helping patients respond adaptively to stressful situations rather than resorting to substances as a coping mechanism. Activities like jogging, brisk walking, and low-impact aerobics sessions have been linked to reduced impulsivity and improved emotional control [28]. Additionally, mindfulness training through activities such as yoga can help patients become more aware of their emotions and bodily states, reducing impulsivity and facilitating a calmer, more reflective response to daily challenges [25,26,27,37]. This is particularly beneficial for patients with alcohol or opioid dependencies, who tend to have impaired emotional regulation and are at a higher risk of relapse during times of elevated stress.

PA, through its positive effects on mood and energy, can also enhance patients’ intrinsic motivation to maintain abstinence [33]. Farhana et al. [23] observed that patients who incorporate PA into their treatment programs report higher levels of motivation to continue their therapeutic journey and maintain a healthy lifestyle. PA not only makes patients more proactive but also reduces symptoms of anhedonia and apathy, which are common depression symptoms associated with SUDs. Acting as a natural antidepressant, PA stimulates the release of positive neurotransmitters and enhances neurogenesis, counteracting depressive symptoms and reducing the likelihood of relapse during periods of low mood and isolation.

Another indirect psychological benefit of PA is the improvement in sleep quality. Sleep disturbances are common among SUD patients, as chronic substance use can disrupt circadian rhythms and impair rest quality [39]. Poor sleep increases relapse risk, leaving patients more vulnerable and less resilient to stressors. PA, particularly aerobic exercises, has been shown to improve sleep quality, contributing to overall psychophysical well-being and reducing relapse risk.

Concerning neurobiological mechanisms, neuroplasticity refers to the brain’s ability to reorganize itself by forming new neural connections in response to learning, experience, or environmental changes. This process is essential for recovery in individuals with SUDs, as substance abuse often alters the brain’s reward system, particularly in areas such as dopamine pathways, the prefrontal cortex, and the nucleus accumbens. These changes contribute to the dysregulation of reward processing and increased susceptibility to cravings, stress, and relapse [34]. The beneficial effects of PA on SUDs are supported by neurobiological mechanisms involving dopamine and brain-derived neurotrophic factor (BDNF), both of which are crucial for neuronal plasticity [9,10,11,12,13]. BDNF is known to facilitate the growth and differentiation of new neurons and synapses, especially in regions that are vulnerable to the damaging effects of substance abuse, such as the hippocampus and prefrontal cortex. Physical activity, especially moderate to intense aerobic exercise, has been shown to enhance PFC function by promoting the release of BDNF and improving synaptic plasticity in this critical area.

Studies indicate that PA reduces cravings by decreasing the hyperactivity of brain regions associated with reward processing, such as the nucleus accumbens [40].

These changes are important for relapse prevention, as the ability to manage emotional responses and make well-informed decisions is vital for maintaining abstinence and resisting the temptation of substance use [23].

Drugs of abuse often cause a massive surge of dopamine in the brain’s reward centers, leading to feelings of euphoria and reinforcing addictive behavior. Over time, however, the brain’s natural reward system becomes less responsive, requiring larger amounts of the substance to achieve the same effect. This phenomenon, known as dopamine dysregulation, contributes to the compulsive nature of addiction [34].

Exercise has been shown to restore balance in the dopaminergic system, particularly through the enhancement of dopamine receptor sensitivity and the release of dopamine itself. Regular PA helps re-establish healthier reward circuits by increasing dopamine transporter activity and promoting the release of dopamine in areas like the striatum, which is involved in both reward and motor functions [23]. Physical exercise positively impacts brain circuits associated with reward and pleasure, as demonstrated by Jamurtas et al. [14], who observed increased beta-endorphins and mood improvement in subjects with SUD.

Another innovative aspect of PA’s neurobiological effects is its influence on the endocannabinoid system (ECS), which is involved in regulating mood, pain, reward, and stress [19]. The ECS plays a crucial role in modulating the brain’s response to addictive substances and is implicated in both the reinforcing and anti-reward effects of drugs.

Physical activity has been found to increase the levels of endocannabinoids such as anandamide and 2-AG, which bind to cannabinoid receptors in the brain, particularly in regions associated with stress and emotional regulation.

Exercise-induced activation of the ECS may explain the reduction in stress and anxiety often reported by individuals engaging in PA, as well as its role in attenuating cravings. This mechanism is particularly relevant for individuals recovering from SUDs, as dysregulated stress response systems and heightened anxiety are common triggers for relapse. These mechanisms also underscore the potential for PA to mitigate stress-related triggers of relapse and enhance emotional regulation, particularly in populations with heightened anxiety or comorbid post-traumatic stress disorder (PTSD) [41].

By modulating the ECS, PA not only supports emotional stability but may also reduce the negative emotional states that often accompany withdrawal and recovery.

One of the most compelling ways in which PA influences brain plasticity is through its effects on stress-related pathways, particularly the hypothalamic-pituitary-adrenal (HPA) axis. Chronic substance use leads to an overactive HPA axis, which results in heightened cortisol levels, impairing emotional regulation and making the individual more vulnerable to relapse [19]. Furthermore, physical activity can complement other therapeutic interventions, such as Cognitive Behavioral Therapy (CBT), by enhancing cognitive and emotional regulation [37]. The synergistic effects of combining PA with psychological therapies may lead to more robust outcomes in terms of relapse prevention and long-term recovery. Importantly, the neuroplastic effects of PA are not limited to short-term improvements; the brain’s capacity for change remains a dynamic process that continues to evolve with sustained exercise over time, offering ongoing benefits for individuals in recovery.

Moreover, the promotion of neuroplasticity through mechanisms like increased brain-derived neurotrophic factor (BDNF) levels not only aids in cognitive recovery but also supports emotional resilience. These changes underscore the importance of incorporating exercise into SUD therapy to address both the physiological and psychological aspects of recovery [42].

In recent years, there has been a growing interest in the application of biomarkers and innovative technologies to enhance the effectiveness and sustainability of therapeutic programs for SUDs. The use of biomarkers such as brain-derived neurotrophic factor (BDNF) and dopamine transporter activity levels has shown potential in personalizing physical activity (PA) interventions to optimize their neurobiological benefits. Additionally, emerging tools like functional magnetic resonance imaging (fMRI) and neurofeedback systems enable real-time monitoring of brain adaptations during PA-based rehabilitation, offering insights into the individual variability in treatment responses [8,13,40].

Beyond neurobiological biomarkers, advanced technologies such as virtual reality (VR) and augmented reality (AR) are being explored as complementary tools in SUD rehabilitation. These technologies create immersive environments that can simulate real-world triggers, allowing patients to practice adaptive responses while engaging in PA. For example, VR-based interventions have been effective in reducing cravings and improving emotional regulation by combining cognitive-behavioral strategies with physical engagement [19,37]. Incorporating these innovations into PA programs can help tailor interventions to individual needs, improve adherence, and provide scalable solutions for diverse patient populations. Future studies should focus on validating these tools in clinical settings, assessing their long-term impact on relapse prevention, and integrating them with traditional therapeutic approaches for a comprehensive rehabilitation model.

Concerning the choice of PA type and its intensity, studies show that it can play a critical role in the effectiveness of SUD treatment. Recent studies highlight how certain types of physical exercise may have specific effects depending on the type of dependency, patient recovery phase, and any psychiatric comorbidities. Aerobic exercises, such as running, brisk walking, swimming, and cycling, are among the most studied activities for their impact on SUDs, particularly for stimulant dependencies like cocaine and methamphetamines. These exercises are known for their ability to promote the release of neurotransmitters such as dopamine, serotonin, and endorphins, all key elements in countering cravings for psychoactive substances and improving mood [15]. Some studies suggest that aerobic exercise can mimic the dopamine spike typically triggered by drugs, providing a positive effect that helps reduce cravings and the risk of relapse [4].

Xu et al. reported a reduction in craving symptoms among methamphetamine-dependent participants following a 12-week moderate-intensity exercise intervention. This effect was accompanied by enhanced working memory, suggesting that cognitive improvements may contribute to better craving management and increased self-control [43].

Another advantage of aerobic exercises is their flexibility and accessibility: patients can practice them in structured facilities, such as gyms or outdoors. Additionally, their intensity can be adjusted based on the patient’s physical capabilities and motivation level, allowing for a personalized program that enhances adherence. However, since high-intensity aerobic exercises may not be suitable for patients with pre-existing cardiovascular conditions or mobility issues, it is important to select appropriate intensity and duration for each individual. Mind-body activities, such as yoga, Tai Chi, and Qi Gong, are emerging as particularly useful complementary tools for opioid and alcohol dependencies [44]. These exercises focus not only on physical movement but also on body awareness and breath regulation, making them ideal for helping patients develop better emotional management and greater interoceptive awareness [31].

Recent studies show that mind-body activities can reduce cortisol and promote a sense of calm and well-being. This effect is particularly beneficial for SUD patients dealing with comorbidities such as anxiety and PTSD, which are often present in opioid dependencies. In addition to enhancing psychological resilience, mind-body activities improve self-regulation capacity, a crucial quality for avoiding relapse [32]. Since many individuals with SUDs tend to react impulsively to craving stimuli, exercises like yoga and Tai Chi can teach response management techniques, helping to reduce impulsivity and respond more calmly to stressors.

It has been observed that patients participating in yoga programs for several weeks show reductions in craving scores and improvements in sleep quality, another factor that can help prevent relapse [23,45]. Although less studied in relation to SUDs compared to aerobic and mind-body exercises, high-intensity interval training (HIIT) programs are gaining interest for their potential to improve physical endurance and stimulate significant neurobiological changes, such as increased levels of brain-derived neurotrophic factor (BDNF), which can support neuroplasticity and recovery of brain areas damaged by chronic substance use [4].

The benefit of HIIT programs for SUD patients appears to lie in their ability to stimulate a rapid endocrine response, promoting stress resilience and enhancing tolerance for physical and psychological discomfort. However, their high intensity may not be suitable for all patients, especially those with heart conditions or severe mental health issues. Nonetheless, when appropriately monitored, HIIT programs could offer unique benefits for patients who desire an intensive recovery pathway and are in good physical condition.

Considering the various effects of different types of PA on SUDs, the optimal treatment approach should be personalized, taking into account both the substance of dependence and the patient’s physical and psychological characteristics [34]. For example, in patients with alcohol and opioid dependencies, who often experience anxiety and post-traumatic stress symptoms, mind-body activities may prove particularly effective for long-term management. Conversely, for stimulant dependencies, where craving is prominent, regular aerobic exercises may be more effective in safely mimicking the neurobiological effects of substances, alleviating the desire for consumption.

A further benefit of a personalized approach is that it allows physical activities to be adapted to changes in the patient’s health status and psychological needs throughout recovery. Evidence suggests that an adaptive approach, in which patients start with mind-body activities and progress to higher-intensity programs as they gain strength and resilience, could optimize the therapeutic effectiveness of PA in SUDs.

Moreover, there is growing interest in combining PA with other cutting-edge therapies, such as neuromodulation techniques (e.g., transcranial magnetic stimulation) and pharmacotherapy, to enhance neuroplasticity and further support recovery [46].

Despite the promising evidence on the benefits of PA in SUD rehabilitation, publication bias remains a significant concern in this field. Studies predominantly focus on the positive outcomes of PA, potentially underreporting adverse effects or limitations. This bias may lead to an overly optimistic view of PA as an intervention, without adequately addressing the risks associated with certain psychiatric comorbidities. For instance, in individuals with bipolar disorder, PA might trigger manic or hypomanic episodes, especially with high-intensity regimens [1,34]. Considering the shared neurobiological underpinnings between SUDs and bipolar disorder, such as dopamine dysregulation, further investigation is needed to evaluate the safety and appropriateness of PA for these populations.

4. Limitations of the Current Literature

The body of research on the role of PA in the rehabilitation of individuals with SUDs has provided valuable insights; however, certain limitations must be acknowledged. One prominent issue is the variability in study methodologies, including differences in PA types, intensities, and durations, which complicate direct comparisons and the formulation of standardized treatment protocols [14,15,23]. Many studies rely on self-reported data for PA adherence and outcomes, introducing the risk of recall bias and overestimation of benefits [37].

Another limitation is the underrepresentation of diverse populations in research samples. Most studies focus on homogeneous groups, often excluding individuals with co-occurring mental health conditions or severe physical limitations, despite the high prevalence of such comorbidities in SUD populations [1,23,35]. Furthermore, the literature lacks robust evidence on the potential adverse effects of PA, especially for populations with specific vulnerabilities. For example, patients with bipolar disorder, who may share some neurobiological similarities with SUDs, could experience mood destabilization from certain types of exercise [34,37]. Additionally, the exploration of biomarkers and innovative technologies in PA research for SUDs is still in its infancy. While promising studies have begun to examine the use of neuroimaging and digital health tools for tracking treatment progress, these technologies are not yet widely adopted or validated in clinical settings [19,46]. This gap highlights the need for more longitudinal studies that integrate advanced technologies to provide objective and reproducible data on the long-term benefits and risks of PA interventions.

Lastly, publication bias may be a concern, as studies with positive results are more likely to be published, potentially skewing the perception of PA’s efficacy. Comprehensive meta-analyses that include unpublished and null-result studies could provide a more balanced understanding of PA’s role in SUD treatment [15,39].

5. Materials and Methods

5.1. Search Strategy

Search was carried out on 30 September 2024 using main online academic databases. These were the databases consulted: PubMed, Web of Science, Google Scholar, and Scopus. To ensure comprehensive coverage of the literature for this narrative review, the following keywords were utilized for each thematic area analyzed in the study. The search terms were combined using Boolean operators (AND, OR) to refine the search results effectively: 1. Physical Activity and Substance Use Disorders, Keywords: “physical activity”, “exercise”, “substance use”, “substance use disorder”, “addiction”, “rehabilitation”, “therapy”, “recovery”, “treatment outcomes”, “addiction recovery”; 2. Neurobiological Mechanisms, Keywords: “dopamine”, “reward system”, “brain plasticity”, “neurotransmitters”, “endogenous opioids”, “stress regulation”, “neurobiological changes”, “craving reduction”, “executive function”, “neuroadaptation”; 3. Psychological Benefits of Physical Activity, Keywords: “stress management”, “mood enhancement”, “self-esteem”, “anxiety reduction”, “depression management”, “coping mechanisms”, “psychological resilience”, “behavioural activation”, “emotional regulation”; 4. Social Benefits of Physical Activity, Keywords: “social support”, “community engagement”, “peer support”, “social integration”, “group exercise”, “team sports”, “social networks”, “isolation reduction”; 5. Intervention Studies and Effectiveness, Keywords: “clinical trials”, “intervention studies”, “effectiveness”, “outcomes”, “exercise programs”, “structured physical activity”, “randomized controlled trials”, “observational studies”; 6. Comparative Approaches, Keywords: “physical activity vs. traditional therapies”, “multimodal approaches”, “combined interventions”, “exercise and pharmacotherapy”, “alternative treatments”, “comparative effectiveness”. Studies published from 1988 to 2024 and written in English were considered for screening.

5.2. Inclusion and Exclusion Criteria

Criteria for inclusion were randomized clinical trials, cohort studies, reviews, and meta-analyses addressing physical activity in substance use disorder rehabilitation. Criteria for exclusion were single case reports with limited clinical applicability and studies focusing solely on pharmacological or psychotherapeutic treatments or alternative treatments without PA integration. Abstracts, conference proceedings, and articles lacking full-text availability were also excluded.

5.3. Data Extraction

Initial screening was performed by the first author through the review of titles and abstracts. Full-text articles were subsequently reviewed based on the inclusion criteria. The most relevant articles were then selected based on the research field, which included the neurobiological mechanisms underlying the effect of physical activity on the rehabilitation of individuals with Substance Use Disorders, its effects on abstinence and craving, its impact on quality of life and mental health, the search for neurobiological markers, and the differences between various types of exercise and different psychoactive substances. Divergences were resolved through discussion with the other authors.

6. Barriers to Participation and Strategies to Enhance Adherence

Despite documented benefits, many SUD patients face difficulties in maintaining commitment to PA, often due to a lack of adequate facilities, social support, and motivation. Literature suggests that barriers may be physical, psychological, social, and logistical, with each aspect requiring specific intervention strategies to promote sustained participation [3,47]. Recent studies show that an approach based on personalized programs, education on PA benefits, and ongoing support can significantly improve adherence and treatment outcomes in SUDs [4,23,34].

Moreover, the variety of interventions analyzed underscores the importance of offering flexible, patient-centered programs that cater to diverse preferences and capacities [48].

Regarding psychological barriers, low motivation, poor self-esteem, and social anxiety are significant obstacles to participation in PA programs. SUD patients often exhibit symptoms of depression and apathy, which negatively impact motivation to engage in physical activity. Low self-esteem is also common and may lead patients to avoid PA due to fear of being unable to sustain regular activity or fear of being judged by others [49]. Social anxiety is particularly high among SUD patients, as many feel vulnerable in public or group settings, fearing comparison with others [19].

To overcome these barriers, psychological support and encouragement of self-efficacy are essential strategies. Orientation sessions can help patients set realistic goals and personalize their programs, reducing performance anxiety and increasing confidence in their abilities. Studies indicate that starting with low-intensity exercises in private settings or individual sessions can help alleviate social anxiety and ease patients into PA programs [15,25,50]. Additionally, motivation techniques such as progress tracking and positive reinforcement increase self-efficacy, encouraging patients to continue with the program [3]. To address psychological barriers such as stigma or lack of awareness about PA’s benefits, incorporating group-based interventions or mindfulness-focused activities like yoga has shown promise. These approaches not only foster community but also help mitigate resistance to treatment by creating a supportive environment [51].

Regarding physical barriers, many SUD patients suffer from chronic physical conditions due to prolonged substance use, which can limit their ability to engage in intense physical activities. Cardiovascular issues, respiratory problems, and muscle pain are common in this patient group, making it challenging to commit to activities requiring sustained effort. Physical withdrawal symptoms, such as fatigue and weakness, can also hinder regular participation in the first months of treatment [37].

To address physical barriers, it is essential to tailor PA programs to patients’ physical capabilities. Studies suggest that low-impact exercises like walking, swimming, and stretching are particularly effective for improving physical fitness without placing additional stress on the body [23]. McDonagh et al. [50] highlight that involving physical therapists or specialized trainers can help patients start safely, with a gradual and supervised PA program adapted to their physical abilities, thereby reducing the risk of dropout due to physical difficulties.

For many patients, limited access to sports facilities, lack of financial resources, and time constraints are significant logistical barriers. Financial difficulties are a particularly serious issue for those who have lost their jobs or face financial struggles due to addiction. Additionally, a lack of transportation or distance from sports facilities can limit participation [49]. Furthermore, for patients who need to balance treatment with work and family commitments, time is often a limiting factor that discourages them from engaging in PA [52].

To reduce logistical barriers, home-based programs and physical activities that do not require expensive equipment or specific spaces can be promoted. Studies show that exercises such as jogging, bodyweight exercises, and brisk walking are highly accessible and effective, requiring minimal investment [4]. Using monitoring apps and exercise video guides for home-based activities allows patients to participate flexibly, eliminating the need to attend expensive or distant facilities. For those with time constraints, shorter sessions distributed throughout the day can be recommended, allowing them to accumulate benefits even with minimal intervals of activity [15].

Lack of social support is also a crucial barrier for many SUD patients, who often live in isolation or have limited social networks. This isolation reduces motivation to participate in physical activities and increases the risk of early dropout [42]. Patients lacking support may struggle to maintain a long-term commitment, as they lack a supportive context to encourage them to pursue their recovery goals [18]. Wright et al. [18] suggest that small support groups within PA programs can provide patients with a safe space to share experiences and encourage each other, creating a supportive environment that enhances mutual commitment.

The participation of family members in PA activities, where possible, can also offer additional support, improving adherence and assisting the patient in their struggle against addiction [3]. An often underestimated barrier to participation is the lack of awareness of the benefits PA can bring to SUD treatment. Many patients view PA as an optional or secondary activity compared to other therapies, such as pharmacotherapy or psychotherapy, and do not fully understand its potential positive effects on relapse prevention.

To increase awareness and motivation, the literature recommends integrating PA education into treatment programs, offering informative sessions on specific benefits such as reducing craving symptoms and positively impacting mood [50]. Patient testimonials and presentations of research findings can reinforce the perception of PA as an essential component of the recovery journey [34].

Additionally, without a regular monitoring and feedback system, many patients may easily lose motivation to participate in a PA program. The lack of feedback limits the perception of progress, making it easier for patients to drop out of the program [37]. Monitoring programs, such as using fitness applications or wearable devices, provide immediate feedback on progress and encourage patients to continue. Pebole et al. [49] highlight that regular monitoring and weekly feedback from healthcare providers significantly boost motivation and improve adherence to PA programs. Follow-up sessions with trainers can help patients maintain motivation and tailor programs to their physical and psychological needs, reducing the risk of early dropout [4].

7. Recommendations and Practical Implications

This review highlights the significant role of physical activity in the treatment and rehabilitation of individuals with Substance Use Disorders. Evidence demonstrates that PA improves physical, psychological, and behavioral outcomes, and translating these findings into actionable strategies for clinical and community settings is essential.

A key recommendation is that PA programs should be tailored to individual characteristics, such as the type of substance used, comorbidities, age, fitness level, and personal preferences. Personalized interventions enhance adherence and optimize therapeutic outcomes [33]. For instance, activities like yoga or walking may be more suitable for individuals with physical limitations, while running or strength training might be appropriate for those seeking greater physical challenges.

The integration of PA into multimodal treatment approaches, such as combining it with cognitive-behavioral therapy, motivational interviewing, or pharmacological treatments, offers promising results. Such combinations address the physiological and psychological dimensions of recovery, fostering a holistic pathway for individuals [5,20]. Furthermore, sustained engagement in PA programs can be supported through monitoring mechanisms, such as wearable devices or mobile applications, which provide real-time feedback and reinforce motivation [47].

In practical terms, PA should be systematically incorporated into SUD treatment programs in both clinical and community settings. Accessibility can be improved by offering low-cost or no-cost options, such as community walking groups or home-based exercise plans [21]. Facilities may also allocate resources for hiring exercise specialists or creating dedicated fitness spaces to support these initiatives.

Enhancing adherence to PA programs is critical and can be achieved by addressing common barriers such as a lack of motivation, limited access, and inadequate social support. Starting with low-intensity activities and gradually increasing the intensity builds confidence and prevents overexertion [21]. Group-based programs can create a sense of community, reduce isolation, and improve accountability, while incentive systems, such as rewards or recognition for achieving milestones, can further encourage participation [39]. Healthcare providers play a crucial role in promoting PA for SUD recovery. They should receive training on the benefits of PA and be equipped to address patient concerns, such as physical limitations or skepticism about its effectiveness [5].

Additionally, cultural and contextual adaptations are essential to ensure the relevance and acceptance of PA programs [28]. Incorporating traditional or region-specific activities can enhance engagement and foster greater acceptance among diverse populations. Sustaining these interventions requires collaboration among healthcare systems, community organizations, and policymakers [39]. Establishing long-term funding and prioritizing PA as a preventive and therapeutic tool in SUD treatment can embed these programs into standard care practices. Ultimately, these efforts promise to enhance the accessibility, adherence, and effectiveness of PA programs, significantly improving outcomes for individuals recovering from SUDs.

8. Future Research Directions and the Importance of Longitudinal Clinical Studies

To further consolidate the effectiveness of physical activity as an adjunct therapy for SUDs, longitudinal clinical studies are crucial to monitor long-term effects and fully understand the dose-response relationship between physical activity and patient outcomes. Such studies should explore not only the immediate effects of different PA modalities (aerobic, HIIT, yoga, etc.) but also the sustained benefits over time, particularly concerning relapse prevention and craving management [19,31].

Additionally, it would be valuable to test the integration of physical activity with other treatment modalities, such as Cognitive Behavioral Therapy (CBT) or pharmacological therapy, to assess the efficacy of combined approaches in managing SUDs. Specifically, the use of digital technologies for progress monitoring and program personalization could offer new opportunities for optimizing treatments. Future research should also focus on how to adapt PA programs to different types of addiction (e.g., alcohol, drugs, stimulants) and the specific psychophysical needs of patients, developing personalized therapeutic protocols that maximize benefits and reduce relapse rates [35,49].

Future research should also aim to address gaps in the literature by investigating potential adverse effects of PA in populations with psychiatric comorbidities, such as bipolar disorder. Rigorous randomized controlled trials are necessary to mitigate publication bias and provide a balanced understanding of both the benefits and risks of PA in diverse patient groups. Additionally, studies should explore personalized approaches that adapt PA regimens to the unique needs of individuals with co-occurring mental health conditions [23,30]. Incorporating innovative technologies, such as virtual reality and biomarker monitoring, could further enhance the safety and efficacy of these interventions like further revisions or enhancements.

Table 1. Thematic synthesis of the review with key findings.

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Open AccessReview

Efficacy and Clinical Application of Physical Activity in Substance Use Disorder Rehabilitation: A Review on Mechanism and Benefits

by Gaia Calcini ^1,*,Vittorio Bolcato ²,Livio Pietro Tronconi ^3,4 andGiuseppe Basile ^5,61Department of Law, Università degli Studi di Milano-Bicocca, 20126 Milano, Italy²Maria Beatrice Hospital, GVM Care & Research, 50121 Firenze, Italy³Department of Health and Life Sciences, European University of Rome, 00163 Roma, Italy⁴Scientific Directorate, Maria Cecilia Hospital, GVM Care & Research, 48033 Cotignola, Italy⁵Department of Biomedical Sciences and Public Health, University “Politecnica delle Marche” of Ancona, 60124 Ancona, Italy⁶IRCCS Orthopaedic Institute Galeazzi, 20157 Milano, Italy^*Author to whom correspondence should be addressed.Physiologia 2025, 5(1), 7; https://doi.org/10.3390/physiologia5010007Submission received: 12 December 2024 / Revised: 20 January 2025 / Accepted: 5 February 2025 / Published: 12 February 2025(This article belongs to the Special Issue Exercise Physiology and Biochemistry: 2nd Edition) Downloadkeyboard_arrow_down Review Reports Versions Notes

Abstract

Background: Substance Use Disorders (SUDs) are chronic conditions characterized by high relapse rates and significant psychological, physical, and social complications. Despite the availability of traditional pharmacological and psychotherapeutic interventions, many individuals struggle to maintain abstinence. Recently, physical activity (PA) has emerged as a promising complementary intervention. This review aims to examine the existing evidence on the effects of PA in individuals with SUDs, with a particular focus on neurobiological mechanisms. Methods: A narrative review was conducted on 30 September 2024, searching relevant keywords on PubMed, Web of Science, Google Scholar, and Scopus. Randomized clinical trials, cohort studies, reviews, and meta-analyses published between 1988 and 2024 were considered. Results: Fifty studies were included. Key themes included the role of PA in inducing neuroadaptation in individuals with SUDs, which is crucial for relapse prevention and impulse control, and the effects of PA depending on the type of PA and the specific SUD. Neurobiological modifications related to PA are of particular interest in the search for potential biomarkers. Additionally, studies explored the effects of PA on cravings, mental health, and quality of life. The review overall discusses the psychological changes induced by PA during SUD rehabilitation, identifies barriers to participation in PA programs, and suggests clinical and organizational strategies to enhance adherence. Conclusions: Physical activity is a promising adjunctive therapy for the management of Substance Use Disorders. Long-time longitudinal studies and meta-analyses are needed to sustain scientific evidence of efficacy. The success of PA programs moreover depends on overcoming barriers to adherence, including physical, psychological, and logistical challenges.Keywords: substance use disorders; physical activity; relapse prevention; craving reduction; mental health; rehabilitation

1. Introduction

Substance Use Disorders (SUDs) represent a critical challenge in global public health, with far-reaching consequences for individuals, families, and societies. According to Volkow and Blanco [1], SUDs are characterized by chronic, relapsing patterns of compulsive substance use, often accompanied by significant impairments in physical, psychological, and social functioning [1]. The World Health Organization (WHO) highlights that the global burden of SUDs continues to grow, exacerbating healthcare costs, disability rates, and socioeconomic disparities worldwide [2].While traditional treatment approaches, including pharmacotherapy and psychotherapy, have proven effective for many, they often fail to address all facets of SUDs, particularly the integration of physical and behavioral health. Relapse rates remain a significant concern, underscoring the need for innovative and holistic interventions that support long-term recovery [3]. Recent advancements in understanding the neurobiological and psychosocial aspects of SUDs have prompted interest in complementary therapies, such as physical activity (PA), as part of a broader treatment strategy.PA offers a multifaceted approach to recovery, targeting both neurobiological and behavioral pathways. Evidence shows that regular PA enhances neuroplasticity and modulates the brain’s reward system, which is often dysregulated in individuals with SUDs [4]. The literature proposes that exercise can act as a novel treatment for drug addiction by alleviating withdrawal symptoms, reducing cravings, and improving mood through its effects on dopamine regulation and brain-derived neurotrophic factor (BDNF) [4]. Furthermore, studies suggest that PA positively impacts anxiety and depression, which frequently co-occur with SUDs, thereby addressing critical comorbidities that hinder recovery [5,6]. Notably, Giménez-Meseguer et al. reported that exercise tailored to the needs of individuals with SUDs significantly improved their physical health, mood, and psychological well-being, thus highlighting its relevance as a holistic therapeutic tool [7]. Animal studies have also provided insights into the mechanisms underlying PA’s benefits. For example, research on morphine-dependent and ethanol-withdrawn rats demonstrates that voluntary exercise can mitigate anxiety and seizure susceptibility, highlighting the neuroprotective role of PA in addiction recovery [6,8]. These findings provide a foundation for exploring how PA interventions can complement existing treatments and offer new avenues for addressing the complexities of SUDs.This review aims to evaluate evidence supporting PA as an adjunctive therapy for SUDs, focusing on its neurobiological mechanisms, therapeutic benefits, and practical implications for clinical and community settings. By examining the interplay of physical, psychological, and social factors, this review seeks to advance the understanding of PA’s role in promoting recovery and long-term well-being for individuals with SUDs.The review is structured as follows: first, we examine the neurobiological mechanisms through which PA benefits individuals with SUDs. Next, we discuss specific PA interventions and their efficacy in different contexts. Finally, we analyze barriers to implementation and offer recommendations for integrating PA into clinical and community settings.

2. Results

A total of 50 studies met the inclusion criteria and were included in the final review. Results were grouped thematically (Table 1) and further comprehensively discussed, focusing on barriers and strategies for enhancing adherence to PA and future research.

2.1. Neurobiological Mechanisms and Brain Plasticity

The beneficial effects of PA on SUDs are supported by neurobiological mechanisms involving dopamine and brain-derived neurotrophic factor (BDNF), both crucial for neuronal plasticity [9,10,11,12,13]. Lynch et al. [4] hypothesize that PA modulates dopaminergic signaling in the brain, promoting neuronal adaptations that help counter the effects of substances. Physical exercise positively impacts brain circuits associated with reward and pleasure, as demonstrated by Jamurtas et al. [14], who observed increased beta-endorphins and mood improvement in subjects with SUD. Additionally, PA reduces cortisol release, the stress hormone, supporting healthier stress regulation and helping to reduce anxiety, a known relapse trigger [15,16]. Furthermore, the normalization of dopaminergic and glutamatergic activity facilitated by exercise may aid in long-term relapse management [17,18].An exciting frontier in PA research is the exploration of neurobiological markers that can predict an individual’s response to exercise. Understanding the genetic, epigenetic, and molecular mechanisms that underlie individual differences in exercise-induced neuroplasticity could help personalize PA programs for optimal therapeutic effects. Additionally, neuroimaging techniques such as fMRI could be used to observe real-time changes in brain activity and structure in response to exercise, offering deeper insights into how PA influences brain function in patients with SUDs [19].

2.2. Effects on Abstinence and Craving Symptoms

One of the most studied effects of PA in SUDs concerns its ability to reduce craving and withdrawal symptoms [20,21,22]. The meta-analysis by Wang et al. [15] demonstrated that moderate and intense PA programs can significantly increase abstinence rates, with positive effects also observed on physical and psychological withdrawal symptoms, such as irritability, insomnia, and anxiety. Longitudinal studies indicate that PA contributes to reduced relapse rates both in the early months and beyond, suggesting a lasting impact on maintaining abstinence [23,24].

2.3. Benefits of Mental Health and Quality of Life

PA is associated with significant improvements in mental health and quality of life in SUD patients. Farhana et al. [23] report that PA-based interventions, such as aerobic exercises and yoga, reduce symptoms of depression and anxiety, improve mood, and reduce the likelihood of relapse [25,26,27]. A study by Zhu et al. [28] demonstrated that a group aerobic exercise program improved cognitive functions and emotions in SUD patients.These effects are attributed to increased levels of endorphins and serotonin, which can enhance emotional well-being [29,30]. Mind-body exercises like Tai Chi have also proven effective in improving emotional regulation, thereby increasing psychological resilience.

2.4. Differences Among Types of Physical Activity and Their Efficacy in SUDs

The type and intensity of PA play a key role in treating SUDs. Aerobic exercises like running and cycling help reduce cravings for stimulants such as cocaine by boosting dopamine and serotonin levels [4,15]. Mind-body activities like yoga and Tai Chi improve emotional regulation and reduce anxiety, making them effective for opioid and alcohol dependencies [31,32]. High-intensity interval training (HIIT) shows potential for neuroplasticity recovery due to increased BDNF levels but requires careful monitoring [4]. A personalized approach that adapts PA to the patient’s needs and recovery stage is essential for optimizing treatment outcomes [33].

3. Discussion

Beyond its physiological effects, PA offers a range of psychological benefits for individuals with SUDs that can be essential in supporting the recovery process. These benefits include increased resilience, enhanced self-efficacy, strengthened emotional regulation, and an overall reduction in stress and anxiety symptoms, all of which play a crucial role in managing and preventing relapse [34,35,36].Resilience, the ability to cope with difficulties and adapt positively to stressful situations, is an essential aspect for those seeking to overcome addiction. Studies show that PA can help build and strengthen resilience, improving a patient’s ability to face the psychological challenges characteristic of the withdrawal process [34]. This helps patients become more resilient to stressors and develop healthier coping mechanisms than those triggered by substance use [4]. The resilience developed through PA is not merely an immediate effect: long-term studies suggest that as patients continue regular PA, their resilience tends to consolidate [34,37]. This is particularly important for relapse prevention, as resilience helps patients navigate high-risk situations without resorting to destructive behaviors.PA also contributes to improving self-efficacy, defined as a person’s confidence in their ability to perform specific actions to achieve certain results. PA requires discipline, specific and measurable goals, and progressive performance improvements, all of which strengthen self-confidence [35]. During recovery, patients with a high level of self-efficacy are more likely to believe in their ability to maintain abstinence and face daily challenges without resorting to substance use. PA allows patients to experience tangible progress, such as improvements in endurance or physical strength, which can easily translate into a broader perception of their capabilities, including control over their dependency. Progressive exercise programs, where incremental goals are set and achieved, foster self-efficacy and increase motivation, empowering patients to feel in control of their recovery.One of the most immediate and well-documented psychological benefits of PA is its ability to reduce anxiety and stress, common and aggravating factors in SUDs. Anxiety can increase relapse risk and often represents one of the primary reasons patients turn back to substances. PA helps reduce cortisol levels and stimulates endorphin release [15]. Mind-body activities like yoga and Tai Chi have proven effective in reducing anxiety levels in SUD patients.Zhu et al. demonstrated that Tai Chi interventions significantly improved sleep quality and emotional regulation in female patients recovering from amphetamine-type stimulant dependence. These long-term benefits contribute to reduced cravings and relapse risk, emphasizing the importance of incorporating mind-body activities into rehabilitation programs [38].These activities combine physical movement with breathing and mindfulness techniques, allowing for deep relaxation. These exercises not only improve the patient’s emotional state in the short term but also increase awareness of their emotional responses, promoting more effective stress management.PA can also enhance emotional regulation, helping patients respond adaptively to stressful situations rather than resorting to substances as a coping mechanism. Activities like jogging, brisk walking, and low-impact aerobics sessions have been linked to reduced impulsivity and improved emotional control [28]. Additionally, mindfulness training through activities such as yoga can help patients become more aware of their emotions and bodily states, reducing impulsivity and facilitating a calmer, more reflective response to daily challenges [25,26,27,37]. This is particularly beneficial for patients with alcohol or opioid dependencies, who tend to have impaired emotional regulation and are at a higher risk of relapse during times of elevated stress.PA, through its positive effects on mood and energy, can also enhance patients’ intrinsic motivation to maintain abstinence [33]. Farhana et al. [23] observed that patients who incorporate PA into their treatment programs report higher levels of motivation to continue their therapeutic journey and maintain a healthy lifestyle. PA not only makes patients more proactive but also reduces symptoms of anhedonia and apathy, which are common depression symptoms associated with SUDs. Acting as a natural antidepressant, PA stimulates the release of positive neurotransmitters and enhances neurogenesis, counteracting depressive symptoms and reducing the likelihood of relapse during periods of low mood and isolation.Another indirect psychological benefit of PA is the improvement in sleep quality. Sleep disturbances are common among SUD patients, as chronic substance use can disrupt circadian rhythms and impair rest quality [39]. Poor sleep increases relapse risk, leaving patients more vulnerable and less resilient to stressors. PA, particularly aerobic exercises, has been shown to improve sleep quality, contributing to overall psychophysical well-being and reducing relapse risk.Concerning neurobiological mechanisms, neuroplasticity refers to the brain’s ability to reorganize itself by forming new neural connections in response to learning, experience, or environmental changes. This process is essential for recovery in individuals with SUDs, as substance abuse often alters the brain’s reward system, particularly in areas such as dopamine pathways, the prefrontal cortex, and the nucleus accumbens. These changes contribute to the dysregulation of reward processing and increased susceptibility to cravings, stress, and relapse [34]. The beneficial effects of PA on SUDs are supported by neurobiological mechanisms involving dopamine and brain-derived neurotrophic factor (BDNF), both of which are crucial for neuronal plasticity [9,10,11,12,13]. BDNF is known to facilitate the growth and differentiation of new neurons and synapses, especially in regions that are vulnerable to the damaging effects of substance abuse, such as the hippocampus and prefrontal cortex. Physical activity, especially moderate to intense aerobic exercise, has been shown to enhance PFC function by promoting the release of BDNF and improving synaptic plasticity in this critical area.Studies indicate that PA reduces cravings by decreasing the hyperactivity of brain regions associated with reward processing, such as the nucleus accumbens [40].These changes are important for relapse prevention, as the ability to manage emotional responses and make well-informed decisions is vital for maintaining abstinence and resisting the temptation of substance use [23].Drugs of abuse often cause a massive surge of dopamine in the brain’s reward centers, leading to feelings of euphoria and reinforcing addictive behavior. Over time, however, the brain’s natural reward system becomes less responsive, requiring larger amounts of the substance to achieve the same effect. This phenomenon, known as dopamine dysregulation, contributes to the compulsive nature of addiction [34].Exercise has been shown to restore balance in the dopaminergic system, particularly through the enhancement of dopamine receptor sensitivity and the release of dopamine itself. Regular PA helps re-establish healthier reward circuits by increasing dopamine transporter activity and promoting the release of dopamine in areas like the striatum, which is involved in both reward and motor functions [23]. Physical exercise positively impacts brain circuits associated with reward and pleasure, as demonstrated by Jamurtas et al. [14], who observed increased beta-endorphins and mood improvement in subjects with SUD.Another innovative aspect of PA’s neurobiological effects is its influence on the endocannabinoid system (ECS), which is involved in regulating mood, pain, reward, and stress [19]. The ECS plays a crucial role in modulating the brain’s response to addictive substances and is implicated in both the reinforcing and anti-reward effects of drugs.Physical activity has been found to increase the levels of endocannabinoids such as anandamide and 2-AG, which bind to cannabinoid receptors in the brain, particularly in regions associated with stress and emotional regulation.Exercise-induced activation of the ECS may explain the reduction in stress and anxiety often reported by individuals engaging in PA, as well as its role in attenuating cravings. This mechanism is particularly relevant for individuals recovering from SUDs, as dysregulated stress response systems and heightened anxiety are common triggers for relapse. These mechanisms also underscore the potential for PA to mitigate stress-related triggers of relapse and enhance emotional regulation, particularly in populations with heightened anxiety or comorbid post-traumatic stress disorder (PTSD) [41].By modulating the ECS, PA not only supports emotional stability but may also reduce the negative emotional states that often accompany withdrawal and recovery.One of the most compelling ways in which PA influences brain plasticity is through its effects on stress-related pathways, particularly the hypothalamic-pituitary-adrenal (HPA) axis. Chronic substance use leads to an overactive HPA axis, which results in heightened cortisol levels, impairing emotional regulation and making the individual more vulnerable to relapse [19]. Furthermore, physical activity can complement other therapeutic interventions, such as Cognitive Behavioral Therapy (CBT), by enhancing cognitive and emotional regulation [37]. The synergistic effects of combining PA with psychological therapies may lead to more robust outcomes in terms of relapse prevention and long-term recovery. Importantly, the neuroplastic effects of PA are not limited to short-term improvements; the brain’s capacity for change remains a dynamic process that continues to evolve with sustained exercise over time, offering ongoing benefits for individuals in recovery.Moreover, the promotion of neuroplasticity through mechanisms like increased brain-derived neurotrophic factor (BDNF) levels not only aids in cognitive recovery but also supports emotional resilience. These changes underscore the importance of incorporating exercise into SUD therapy to address both the physiological and psychological aspects of recovery [42].In recent years, there has been a growing interest in the application of biomarkers and innovative technologies to enhance the effectiveness and sustainability of therapeutic programs for SUDs. The use of biomarkers such as brain-derived neurotrophic factor (BDNF) and dopamine transporter activity levels has shown potential in personalizing physical activity (PA) interventions to optimize their neurobiological benefits. Additionally, emerging tools like functional magnetic resonance imaging (fMRI) and neurofeedback systems enable real-time monitoring of brain adaptations during PA-based rehabilitation, offering insights into the individual variability in treatment responses [8,13,40].Beyond neurobiological biomarkers, advanced technologies such as virtual reality (VR) and augmented reality (AR) are being explored as complementary tools in SUD rehabilitation. These technologies create immersive environments that can simulate real-world triggers, allowing patients to practice adaptive responses while engaging in PA. For example, VR-based interventions have been effective in reducing cravings and improving emotional regulation by combining cognitive-behavioral strategies with physical engagement [19,37]. Incorporating these innovations into PA programs can help tailor interventions to individual needs, improve adherence, and provide scalable solutions for diverse patient populations. Future studies should focus on validating these tools in clinical settings, assessing their long-term impact on relapse prevention, and integrating them with traditional therapeutic approaches for a comprehensive rehabilitation model.Concerning the choice of PA type and its intensity, studies show that it can play a critical role in the effectiveness of SUD treatment. Recent studies highlight how certain types of physical exercise may have specific effects depending on the type of dependency, patient recovery phase, and any psychiatric comorbidities. Aerobic exercises, such as running, brisk walking, swimming, and cycling, are among the most studied activities for their impact on SUDs, particularly for stimulant dependencies like cocaine and methamphetamines. These exercises are known for their ability to promote the release of neurotransmitters such as dopamine, serotonin, and endorphins, all key elements in countering cravings for psychoactive substances and improving mood [15]. Some studies suggest that aerobic exercise can mimic the dopamine spike typically triggered by drugs, providing a positive effect that helps reduce cravings and the risk of relapse [4].Xu et al. reported a reduction in craving symptoms among methamphetamine-dependent participants following a 12-week moderate-intensity exercise intervention. This effect was accompanied by enhanced working memory, suggesting that cognitive improvements may contribute to better craving management and increased self-control [43].Another advantage of aerobic exercises is their flexibility and accessibility: patients can practice them in structured facilities, such as gyms or outdoors. Additionally, their intensity can be adjusted based on the patient’s physical capabilities and motivation level, allowing for a personalized program that enhances adherence. However, since high-intensity aerobic exercises may not be suitable for patients with pre-existing cardiovascular conditions or mobility issues, it is important to select appropriate intensity and duration for each individual. Mind-body activities, such as yoga, Tai Chi, and Qi Gong, are emerging as particularly useful complementary tools for opioid and alcohol dependencies [44]. These exercises focus not only on physical movement but also on body awareness and breath regulation, making them ideal for helping patients develop better emotional management and greater interoceptive awareness [31].Recent studies show that mind-body activities can reduce cortisol and promote a sense of calm and well-being. This effect is particularly beneficial for SUD patients dealing with comorbidities such as anxiety and PTSD, which are often present in opioid dependencies. In addition to enhancing psychological resilience, mind-body activities improve self-regulation capacity, a crucial quality for avoiding relapse [32]. Since many individuals with SUDs tend to react impulsively to craving stimuli, exercises like yoga and Tai Chi can teach response management techniques, helping to reduce impulsivity and respond more calmly to stressors.It has been observed that patients participating in yoga programs for several weeks show reductions in craving scores and improvements in sleep quality, another factor that can help prevent relapse [23,45]. Although less studied in relation to SUDs compared to aerobic and mind-body exercises, high-intensity interval training (HIIT) programs are gaining interest for their potential to improve physical endurance and stimulate significant neurobiological changes, such as increased levels of brain-derived neurotrophic factor (BDNF), which can support neuroplasticity and recovery of brain areas damaged by chronic substance use [4].The benefit of HIIT programs for SUD patients appears to lie in their ability to stimulate a rapid endocrine response, promoting stress resilience and enhancing tolerance for physical and psychological discomfort. However, their high intensity may not be suitable for all patients, especially those with heart conditions or severe mental health issues. Nonetheless, when appropriately monitored, HIIT programs could offer unique benefits for patients who desire an intensive recovery pathway and are in good physical condition.Considering the various effects of different types of PA on SUDs, the optimal treatment approach should be personalized, taking into account both the substance of dependence and the patient’s physical and psychological characteristics [34]. For example, in patients with alcohol and opioid dependencies, who often experience anxiety and post-traumatic stress symptoms, mind-body activities may prove particularly effective for long-term management. Conversely, for stimulant dependencies, where craving is prominent, regular aerobic exercises may be more effective in safely mimicking the neurobiological effects of substances, alleviating the desire for consumption.A further benefit of a personalized approach is that it allows physical activities to be adapted to changes in the patient’s health status and psychological needs throughout recovery. Evidence suggests that an adaptive approach, in which patients start with mind-body activities and progress to higher-intensity programs as they gain strength and resilience, could optimize the therapeutic effectiveness of PA in SUDs.Moreover, there is growing interest in combining PA with other cutting-edge therapies, such as neuromodulation techniques (e.g., transcranial magnetic stimulation) and pharmacotherapy, to enhance neuroplasticity and further support recovery [46].Despite the promising evidence on the benefits of PA in SUD rehabilitation, publication bias remains a significant concern in this field. Studies predominantly focus on the positive outcomes of PA, potentially underreporting adverse effects or limitations. This bias may lead to an overly optimistic view of PA as an intervention, without adequately addressing the risks associated with certain psychiatric comorbidities. For instance, in individuals with bipolar disorder, PA might trigger manic or hypomanic episodes, especially with high-intensity regimens [1,34]. Considering the shared neurobiological underpinnings between SUDs and bipolar disorder, such as dopamine dysregulation, further investigation is needed to evaluate the safety and appropriateness of PA for these populations.

4. Limitations of the Current Literature

The body of research on the role of PA in the rehabilitation of individuals with SUDs has provided valuable insights; however, certain limitations must be acknowledged. One prominent issue is the variability in study methodologies, including differences in PA types, intensities, and durations, which complicate direct comparisons and the formulation of standardized treatment protocols [14,15,23]. Many studies rely on self-reported data for PA adherence and outcomes, introducing the risk of recall bias and overestimation of benefits [37].Another limitation is the underrepresentation of diverse populations in research samples. Most studies focus on homogeneous groups, often excluding individuals with co-occurring mental health conditions or severe physical limitations, despite the high prevalence of such comorbidities in SUD populations [1,23,35]. Furthermore, the literature lacks robust evidence on the potential adverse effects of PA, especially for populations with specific vulnerabilities. For example, patients with bipolar disorder, who may share some neurobiological similarities with SUDs, could experience mood destabilization from certain types of exercise [34,37]. Additionally, the exploration of biomarkers and innovative technologies in PA research for SUDs is still in its infancy. While promising studies have begun to examine the use of neuroimaging and digital health tools for tracking treatment progress, these technologies are not yet widely adopted or validated in clinical settings [19,46]. This gap highlights the need for more longitudinal studies that integrate advanced technologies to provide objective and reproducible data on the long-term benefits and risks of PA interventions.Lastly, publication bias may be a concern, as studies with positive results are more likely to be published, potentially skewing the perception of PA’s efficacy. Comprehensive meta-analyses that include unpublished and null-result studies could provide a more balanced understanding of PA’s role in SUD treatment [15,39].

5. Materials and Methods

5.1. Search Strategy

Search was carried out on 30 September 2024 using main online academic databases. These were the databases consulted: PubMed, Web of Science, Google Scholar, and Scopus. To ensure comprehensive coverage of the literature for this narrative review, the following keywords were utilized for each thematic area analyzed in the study. The search terms were combined using Boolean operators (AND, OR) to refine the search results effectively: 1. Physical Activity and Substance Use Disorders, Keywords: “physical activity”, “exercise”, “substance use”, “substance use disorder”, “addiction”, “rehabilitation”, “therapy”, “recovery”, “treatment outcomes”, “addiction recovery”; 2. Neurobiological Mechanisms, Keywords: “dopamine”, “reward system”, “brain plasticity”, “neurotransmitters”, “endogenous opioids”, “stress regulation”, “neurobiological changes”, “craving reduction”, “executive function”, “neuroadaptation”; 3. Psychological Benefits of Physical Activity, Keywords: “stress management”, “mood enhancement”, “self-esteem”, “anxiety reduction”, “depression management”, “coping mechanisms”, “psychological resilience”, “behavioural activation”, “emotional regulation”; 4. Social Benefits of Physical Activity, Keywords: “social support”, “community engagement”, “peer support”, “social integration”, “group exercise”, “team sports”, “social networks”, “isolation reduction”; 5. Intervention Studies and Effectiveness, Keywords: “clinical trials”, “intervention studies”, “effectiveness”, “outcomes”, “exercise programs”, “structured physical activity”, “randomized controlled trials”, “observational studies”; 6. Comparative Approaches, Keywords: “physical activity vs. traditional therapies”, “multimodal approaches”, “combined interventions”, “exercise and pharmacotherapy”, “alternative treatments”, “comparative effectiveness”. Studies published from 1988 to 2024 and written in English were considered for screening.

5.2. Inclusion and Exclusion Criteria

Criteria for inclusion were randomized clinical trials, cohort studies, reviews, and meta-analyses addressing physical activity in substance use disorder rehabilitation. Criteria for exclusion were single case reports with limited clinical applicability and studies focusing solely on pharmacological or psychotherapeutic treatments or alternative treatments without PA integration. Abstracts, conference proceedings, and articles lacking full-text availability were also excluded.

5.3. Data Extraction

Initial screening was performed by the first author through the review of titles and abstracts. Full-text articles were subsequently reviewed based on the inclusion criteria. The most relevant articles were then selected based on the research field, which included the neurobiological mechanisms underlying the effect of physical activity on the rehabilitation of individuals with Substance Use Disorders, its effects on abstinence and craving, its impact on quality of life and mental health, the search for neurobiological markers, and the differences between various types of exercise and different psychoactive substances. Divergences were resolved through discussion with the other authors.

6. Barriers to Participation and Strategies to Enhance Adherence

Despite documented benefits, many SUD patients face difficulties in maintaining commitment to PA, often due to a lack of adequate facilities, social support, and motivation. Literature suggests that barriers may be physical, psychological, social, and logistical, with each aspect requiring specific intervention strategies to promote sustained participation [3,47]. Recent studies show that an approach based on personalized programs, education on PA benefits, and ongoing support can significantly improve adherence and treatment outcomes in SUDs [4,23,34].Moreover, the variety of interventions analyzed underscores the importance of offering flexible, patient-centered programs that cater to diverse preferences and capacities [48].Regarding psychological barriers, low motivation, poor self-esteem, and social anxiety are significant obstacles to participation in PA programs. SUD patients often exhibit symptoms of depression and apathy, which negatively impact motivation to engage in physical activity. Low self-esteem is also common and may lead patients to avoid PA due to fear of being unable to sustain regular activity or fear of being judged by others [49]. Social anxiety is particularly high among SUD patients, as many feel vulnerable in public or group settings, fearing comparison with others [19].To overcome these barriers, psychological support and encouragement of self-efficacy are essential strategies. Orientation sessions can help patients set realistic goals and personalize their programs, reducing performance anxiety and increasing confidence in their abilities. Studies indicate that starting with low-intensity exercises in private settings or individual sessions can help alleviate social anxiety and ease patients into PA programs [15,25,50]. Additionally, motivation techniques such as progress tracking and positive reinforcement increase self-efficacy, encouraging patients to continue with the program [3]. To address psychological barriers such as stigma or lack of awareness about PA’s benefits, incorporating group-based interventions or mindfulness-focused activities like yoga has shown promise. These approaches not only foster community but also help mitigate resistance to treatment by creating a supportive environment [51].Regarding physical barriers, many SUD patients suffer from chronic physical conditions due to prolonged substance use, which can limit their ability to engage in intense physical activities. Cardiovascular issues, respiratory problems, and muscle pain are common in this patient group, making it challenging to commit to activities requiring sustained effort. Physical withdrawal symptoms, such as fatigue and weakness, can also hinder regular participation in the first months of treatment [37].To address physical barriers, it is essential to tailor PA programs to patients’ physical capabilities. Studies suggest that low-impact exercises like walking, swimming, and stretching are particularly effective for improving physical fitness without placing additional stress on the body [23]. McDonagh et al. [50] highlight that involving physical therapists or specialized trainers can help patients start safely, with a gradual and supervised PA program adapted to their physical abilities, thereby reducing the risk of dropout due to physical difficulties.For many patients, limited access to sports facilities, lack of financial resources, and time constraints are significant logistical barriers. Financial difficulties are a particularly serious issue for those who have lost their jobs or face financial struggles due to addiction. Additionally, a lack of transportation or distance from sports facilities can limit participation [49]. Furthermore, for patients who need to balance treatment with work and family commitments, time is often a limiting factor that discourages them from engaging in PA [52].To reduce logistical barriers, home-based programs and physical activities that do not require expensive equipment or specific spaces can be promoted. Studies show that exercises such as jogging, bodyweight exercises, and brisk walking are highly accessible and effective, requiring minimal investment [4]. Using monitoring apps and exercise video guides for home-based activities allows patients to participate flexibly, eliminating the need to attend expensive or distant facilities. For those with time constraints, shorter sessions distributed throughout the day can be recommended, allowing them to accumulate benefits even with minimal intervals of activity [15].Lack of social support is also a crucial barrier for many SUD patients, who often live in isolation or have limited social networks. This isolation reduces motivation to participate in physical activities and increases the risk of early dropout [42]. Patients lacking support may struggle to maintain a long-term commitment, as they lack a supportive context to encourage them to pursue their recovery goals [18]. Wright et al. [18] suggest that small support groups within PA programs can provide patients with a safe space to share experiences and encourage each other, creating a supportive environment that enhances mutual commitment.The participation of family members in PA activities, where possible, can also offer additional support, improving adherence and assisting the patient in their struggle against addiction [3]. An often underestimated barrier to participation is the lack of awareness of the benefits PA can bring to SUD treatment. Many patients view PA as an optional or secondary activity compared to other therapies, such as pharmacotherapy or psychotherapy, and do not fully understand its potential positive effects on relapse prevention.To increase awareness and motivation, the literature recommends integrating PA education into treatment programs, offering informative sessions on specific benefits such as reducing craving symptoms and positively impacting mood [50]. Patient testimonials and presentations of research findings can reinforce the perception of PA as an essential component of the recovery journey [34].Additionally, without a regular monitoring and feedback system, many patients may easily lose motivation to participate in a PA program. The lack of feedback limits the perception of progress, making it easier for patients to drop out of the program [37]. Monitoring programs, such as using fitness applications or wearable devices, provide immediate feedback on progress and encourage patients to continue. Pebole et al. [49] highlight that regular monitoring and weekly feedback from healthcare providers significantly boost motivation and improve adherence to PA programs. Follow-up sessions with trainers can help patients maintain motivation and tailor programs to their physical and psychological needs, reducing the risk of early dropout [4].

7. Recommendations and Practical Implications

This review highlights the significant role of physical activity in the treatment and rehabilitation of individuals with Substance Use Disorders. Evidence demonstrates that PA improves physical, psychological, and behavioral outcomes, and translating these findings into actionable strategies for clinical and community settings is essential.A key recommendation is that PA programs should be tailored to individual characteristics, such as the type of substance used, comorbidities, age, fitness level, and personal preferences. Personalized interventions enhance adherence and optimize therapeutic outcomes [33]. For instance, activities like yoga or walking may be more suitable for individuals with physical limitations, while running or strength training might be appropriate for those seeking greater physical challenges.The integration of PA into multimodal treatment approaches, such as combining it with cognitive-behavioral therapy, motivational interviewing, or pharmacological treatments, offers promising results. Such combinations address the physiological and psychological dimensions of recovery, fostering a holistic pathway for individuals [5,20]. Furthermore, sustained engagement in PA programs can be supported through monitoring mechanisms, such as wearable devices or mobile applications, which provide real-time feedback and reinforce motivation [47].In practical terms, PA should be systematically incorporated into SUD treatment programs in both clinical and community settings. Accessibility can be improved by offering low-cost or no-cost options, such as community walking groups or home-based exercise plans [21]. Facilities may also allocate resources for hiring exercise specialists or creating dedicated fitness spaces to support these initiatives.Enhancing adherence to PA programs is critical and can be achieved by addressing common barriers such as a lack of motivation, limited access, and inadequate social support. Starting with low-intensity activities and gradually increasing the intensity builds confidence and prevents overexertion [21]. Group-based programs can create a sense of community, reduce isolation, and improve accountability, while incentive systems, such as rewards or recognition for achieving milestones, can further encourage participation [39]. Healthcare providers play a crucial role in promoting PA for SUD recovery. They should receive training on the benefits of PA and be equipped to address patient concerns, such as physical limitations or skepticism about its effectiveness [5].Additionally, cultural and contextual adaptations are essential to ensure the relevance and acceptance of PA programs [28]. Incorporating traditional or region-specific activities can enhance engagement and foster greater acceptance among diverse populations. Sustaining these interventions requires collaboration among healthcare systems, community organizations, and policymakers [39]. Establishing long-term funding and prioritizing PA as a preventive and therapeutic tool in SUD treatment can embed these programs into standard care practices. Ultimately, these efforts promise to enhance the accessibility, adherence, and effectiveness of PA programs, significantly improving outcomes for individuals recovering from SUDs.

8. Future Research Directions and the Importance of Longitudinal Clinical Studies

To further consolidate the effectiveness of physical activity as an adjunct therapy for SUDs, longitudinal clinical studies are crucial to monitor long-term effects and fully understand the dose-response relationship between physical activity and patient outcomes. Such studies should explore not only the immediate effects of different PA modalities (aerobic, HIIT, yoga, etc.) but also the sustained benefits over time, particularly concerning relapse prevention and craving management [19,31].Additionally, it would be valuable to test the integration of physical activity with other treatment modalities, such as Cognitive Behavioral Therapy (CBT) or pharmacological therapy, to assess the efficacy of combined approaches in managing SUDs. Specifically, the use of digital technologies for progress monitoring and program personalization could offer new opportunities for optimizing treatments. Future research should also focus on how to adapt PA programs to different types of addiction (e.g., alcohol, drugs, stimulants) and the specific psychophysical needs of patients, developing personalized therapeutic protocols that maximize benefits and reduce relapse rates [35,49].Future research should also aim to address gaps in the literature by investigating potential adverse effects of PA in populations with psychiatric comorbidities, such as bipolar disorder. Rigorous randomized controlled trials are necessary to mitigate publication bias and provide a balanced understanding of both the benefits and risks of PA in diverse patient groups. Additionally, studies should explore personalized approaches that adapt PA regimens to the unique needs of individuals with co-occurring mental health conditions [23,30]. Incorporating innovative technologies, such as virtual reality and biomarker monitoring, could further enhance the safety and efficacy of these interventions like further revisions or enhancements.Table 1. Thematic synthesis of the review with key findings.

9. Study Limitations

While this review highlights the therapeutic potential of PA in SUDs, it is important to acknowledge its limitations. Firstly, as a narrative review, the study does not employ a systematic approach to data collection, which could introduce selection bias. This limitation is compounded by the inclusion of studies with diverse methodologies and heterogeneous populations, making it challenging to generalize findings. Secondly, most of the evidence comes from small-scale studies, limiting the applicability to broader clinical contexts. The variability in PA interventions, including differences in type, intensity, and duration, further complicates the synthesis of consistent conclusions. Additionally, the review largely focuses on the benefits of PA, with a limited exploration of potential adverse effects or contraindications for specific patient groups.

10. Conclusions

Physical activity is a promising and potentially effective adjunct therapy for managing Substance Use Disorders, contributing to improved mental health and quality of life, reduced craving symptoms, and relapse prevention. Evidence suggests that PA has direct effects on the brain, which are crucial in counteracting the chronic effects of substances, as well as for developing specific biomarkers of efficacy. The continued evolution of research and the application of innovative technologies are essential to improve the effectiveness and sustainability of these therapeutic programs, with the aim of promoting more comprehensive and lasting rehabilitation for patients with Substance Use Disorders.The success of PA programs largely depends on addressing barriers that limit adherence, including physical, psychological, and logistical obstacles, boosting patient motivation and PA accessibility. This also means organizing the social and health services for addiction care with regard to this evidence, thus meeting the needs of health prevention and social integration.Exploring ways to adapt PA programs to different types of addiction and the specific psychophysical needs of patients will pave the way for personalized protocols that could maximize therapeutic benefits and significantly reduce relapse rates, contributing to a holistic and sustainable therapeutic approach.

Introduction

Substance Use Disorders (SUDs) are a major global health issue. They significantly affect individuals, families, and societies. These disorders involve ongoing, compulsive substance use that often leads to serious problems with physical health, mental health, and social life. The World Health Organization (WHO) notes that SUDs continue to increase worldwide, leading to higher healthcare costs, more disabilities, and greater social and economic differences.

Traditional treatments, such as medication and talk therapy, are effective for many. However, they often do not fully address all aspects of SUDs, especially how physical and mental health are connected. High rates of relapse remain a concern, highlighting the need for new, comprehensive approaches that support long-term recovery. Recent discoveries about the brain and social factors of SUDs have led to interest in other therapies, like physical activity (PA), as part of a wider treatment plan.

PA offers many benefits for recovery by working on both brain and behavior. Research shows that regular PA improves brain flexibility and helps regulate the brain's reward system, which is often out of balance in individuals with SUDs. Studies suggest that exercise can serve as a new treatment for addiction. It may ease withdrawal symptoms, reduce cravings, and improve mood by affecting dopamine levels and brain-derived neurotrophic factor (BDNF). Furthermore, PA appears to help with anxiety and depression, conditions commonly seen with SUDs that can hinder recovery. One study found that exercise designed for individuals with SUDs greatly improved their physical health, mood, and mental well-being, showing its value as a complete treatment tool. Animal studies have also offered insights into PA’s benefits. For example, research on rats dependent on morphine or withdrawing from alcohol indicates that voluntary exercise can lessen anxiety and lower seizure risk, pointing to PA’s role in protecting the brain during addiction recovery. These findings lay the groundwork for exploring how PA interventions can support current treatments and open new ways to address the complexities of SUDs.

This review aims to assess the evidence supporting PA as an additional therapy for SUDs. The focus is on how PA affects the brain, its treatment benefits, and how it can be used in clinics and communities. By looking at how physical, mental, and social factors interact, this review seeks to improve understanding of PA’s role in helping individuals with SUDs achieve recovery and lasting well-being.

This review is organized as follows: first, an examination of the brain mechanisms through which PA benefits individuals with SUDs. Next, a discussion of specific PA interventions and their effectiveness in different situations. Finally, an analysis of obstacles to implementing PA and suggestions for adding it to clinical and community settings.

Results

Fifty studies met the requirements and were included in this review. The findings were grouped by theme and discussed in detail, with a focus on challenges and ways to improve participation in physical activity and future research needs.

Neurobiological Mechanisms and Brain Plasticity

Physical activity (PA) helps individuals with Substance Use Disorders (SUDs) through brain processes involving dopamine and brain-derived neurotrophic factor (BDNF), both essential for brain adaptability. Researchers suggest that PA changes dopamine signals in the brain, creating brain adjustments that help counteract the effects of substances. Exercise positively affects brain areas linked to reward and pleasure; for example, increased beta-endorphins and improved mood have been observed in individuals with SUDs. Additionally, PA reduces cortisol, the stress hormone, which supports healthier stress control and helps lower anxiety, a known trigger for relapse. The normalization of brain activity, including dopamine and glutamate, achieved through exercise may also assist in long-term relapse management.

An exciting area of PA research involves identifying brain markers that can predict how individuals respond to exercise. Understanding the genetic and molecular factors behind differences in how exercise changes the brain could help create personalized PA programs for the best treatment results. Also, brain imaging methods like fMRI could be used to see real-time changes in brain activity and structure during exercise, offering deeper insights into how PA affects brain function in individuals with SUDs.

Effects on Abstinence and Craving Symptoms

One significant effect of physical activity (PA) in Substance Use Disorders (SUDs) is its ability to reduce cravings and withdrawal symptoms. A meta-analysis showed that moderate and intense PA programs can greatly increase rates of staying sober. Positive effects were also noted on physical and mental withdrawal symptoms, such as irritability, sleeplessness, and anxiety. Long-term studies indicate that PA helps lower relapse rates, both in the early months and later, suggesting a lasting impact on maintaining sobriety.

Benefits of Mental Health and Quality of Life

Physical activity (PA) is linked to significant improvements in mental health and overall quality of life for individuals with Substance Use Disorders (SUDs). Reports indicate that interventions based on PA, such as aerobic exercises and yoga, reduce symptoms of depression and anxiety, improve mood, and decrease the likelihood of relapse. One study showed that a group aerobic exercise program improved thinking skills and emotions in individuals with SUDs.

These positive effects are thought to be due to increased levels of endorphins and serotonin, which can enhance emotional well-being. Mind-body exercises like Tai Chi have also proven effective in improving emotional control, thereby boosting mental resilience.

Types of Physical Activity and Efficacy in SUDs

The type and intensity of physical activity (PA) play a key role in treating Substance Use Disorders (SUDs). Aerobic exercises, such as running and cycling, help reduce cravings for stimulants like cocaine by increasing dopamine and serotonin levels. Mind-body activities like yoga and Tai Chi improve emotional control and reduce anxiety, making them effective for opioid and alcohol dependencies. High-intensity interval training (HIIT) shows promise for brain recovery due to higher levels of brain-derived neurotrophic factor (BDNF), but it requires careful supervision. A personalized approach that matches PA to an individual's needs and stage of recovery is essential for achieving the best treatment results.

Discussion

Physical activity (PA) offers significant psychological benefits that support recovery from Substance Use Disorders (SUDs). These include increased resilience, improved self-efficacy, better emotional regulation, and a general reduction in stress and anxiety. PA helps individuals cope with challenges and adapt to stressful situations, building resilience important for preventing relapse. It also strengthens self-confidence as individuals achieve physical goals, which translates into a belief in their ability to maintain sobriety. Moreover, PA reduces anxiety and stress by lowering cortisol and releasing endorphins, and mind-body practices like yoga and Tai Chi specifically aid in emotional regulation and sleep quality, which are often disrupted in SUDs. PA also enhances motivation and acts as a natural antidepressant, reducing apathy and anhedonia.

Regarding brain mechanisms, PA promotes neuroplasticity, which is the brain's ability to heal and reorganize itself after being altered by substance use. PA improves dopamine pathways, restores the brain's reward system, and influences the endocannabinoid system, which regulates mood and stress. These changes help reduce cravings and improve emotional stability. PA also helps normalize the hypothalamic-pituitary-adrenal (HPA) axis, which controls the body's stress response, making individuals less vulnerable to relapse triggers. The ongoing nature of these brain changes means sustained exercise offers continuous benefits.

New technologies and biomarkers are improving PA interventions. For example, brain-derived neurotrophic factor (BDNF) levels and dopamine activity can help tailor exercise programs. Tools like functional magnetic resonance imaging (fMRI) and virtual reality (VR) allow real-time monitoring of brain changes and can create immersive environments for practicing coping skills, making PA programs more personalized and effective.

The choice of PA type and intensity is crucial. Aerobic exercises like running can reduce cravings for stimulants by boosting dopamine and serotonin. Mind-body activities such as yoga and Tai Chi are beneficial for opioid and alcohol dependencies due to their focus on emotional management and stress reduction. High-intensity interval training (HIIT) shows potential for brain recovery but requires careful monitoring. The most effective approach involves personalizing PA based on the individual's substance use history, recovery stage, and overall health, potentially combining different types of activity as needs evolve.

Despite strong evidence, concerns about publication bias exist, where positive results are more likely to be reported. This can lead to an overly optimistic view of PA, overlooking potential risks for individuals with certain co-occurring conditions, such as bipolar disorder, where high-intensity exercise might trigger mood instability. Further research is needed to fully understand PA's safety and effectiveness across all populations.

Limitations of Current Research

Research on physical activity (PA) in Substance Use Disorder (SUD) rehabilitation has provided valuable information, but it also has limits. A main issue is the varied methods used across studies, including differences in PA types, intensities, and durations. This makes it hard to compare results directly or create standard treatment plans. Many studies also rely on self-reported information about PA and its effects, which can lead to biased or overly positive findings.

Another limitation is the lack of diversity in study groups. Most research focuses on similar populations, often excluding individuals with co-occurring mental health issues or severe physical limits, even though these are common among people with SUDs. There is also not much strong evidence on potential negative effects of PA, especially for vulnerable groups. For example, individuals with bipolar disorder, who share some brain similarities with SUDs, might experience mood changes from certain exercises. Research into brain markers and new technologies in PA for SUDs is still in early stages. While promising studies exist on using brain imaging and digital tools to track progress, these technologies are not widely used or fully proven in clinical settings. This highlights the need for more long-term studies that use advanced technologies to get objective and reliable data on the benefits and risks of PA interventions over time. Finally, publication bias may be an issue, as studies with positive results are more likely to be published, possibly skewing the understanding of PA's effectiveness. More comprehensive reviews that include all types of study results could offer a more balanced view.

Materials and Methods

Search Strategy

A search was conducted on 30 September 2024, using major online academic databases: PubMed, Web of Science, Google Scholar, and Scopus. To ensure a thorough review of the literature, specific keywords were used for each thematic area of the study. Search terms were combined using Boolean operators (AND, OR) to narrow the results. Keywords included "physical activity," "exercise," "substance use," "substance use disorder," "addiction," "rehabilitation," "therapy," "recovery," "treatment outcomes," "addiction recovery," "dopamine," "reward system," "brain plasticity," "neurotransmitters," "endogenous opioids," "stress regulation," "neurobiological changes," "craving reduction," "executive function," "neuroadaptation," "stress management," "mood enhancement," "self-esteem," "anxiety reduction," "depression management," "coping mechanisms," "psychological resilience," "behavioural activation," "emotional regulation," "social support," "community engagement," "peer support," "social integration," "group exercise," "team sports," "social networks," "isolation reduction," "clinical trials," "intervention studies," "effectiveness," "outcomes," "exercise programs," "structured physical activity," "randomized controlled trials," "observational studies," "physical activity vs. traditional therapies," "multimodal approaches," "combined interventions," "exercise and pharmacotherapy," and "alternative treatments," "comparative effectiveness." Studies published from 1988 to 2024 and written in English were considered.

Inclusion and Exclusion Criteria

Studies included were randomized clinical trials, cohort studies, reviews, and meta-analyses that focused on physical activity in substance use disorder rehabilitation. Studies excluded were single case reports with limited practical use, as well as those focused only on drug or talk therapies, or alternative treatments that did not involve physical activity. Abstracts, conference reports, and articles without full text available were also excluded.

Data Extraction

The initial screening of titles and abstracts was performed by the first author. Full-text articles were then reviewed based on the inclusion criteria. The most relevant articles were chosen based on the research areas, which included brain mechanisms of physical activity on the rehabilitation of individuals with Substance Use Disorders, its effects on sobriety and cravings, its impact on quality of life and mental health, the search for brain markers, and differences among exercise types and substances. Any disagreements were resolved through discussion among the authors.

Barriers to Participation and Strategies to Enhance Adherence

Despite the clear benefits of physical activity (PA), many individuals with Substance Use Disorders (SUDs) find it difficult to stick with PA programs. Common obstacles include limited access to facilities, insufficient social support, and low motivation. Research suggests that these barriers can be physical, psychological, social, and practical, each needing specific strategies to encourage ongoing participation. Overall, a personalized approach, education about PA benefits, and consistent support can greatly improve how well individuals stay in treatment programs and their recovery outcomes.

Psychological barriers are major hindrances. Individuals with SUDs often experience low motivation, poor self-esteem, and social anxiety. They may show symptoms of depression and apathy, making it hard to engage in physical activities. Low self-esteem can lead to avoidance due to fear of failure or judgment. High social anxiety means many feel uneasy in public or group settings. To overcome these, psychological support is vital. Orientation sessions can help set realistic goals, and starting with low-intensity, private, or individual sessions can ease social anxiety. Motivation techniques like tracking progress and positive reinforcement also boost self-confidence and encourage continued engagement. Group interventions or mindfulness activities like yoga can also address stigma and lack of awareness, fostering a supportive environment.

Physical challenges also exist, as many individuals with SUDs have chronic health conditions from prolonged substance use, limiting their ability for intense physical activity. Issues like heart problems, breathing difficulties, and muscle pain are common. Withdrawal symptoms such as fatigue and weakness can also make regular participation difficult early in treatment. To address this, PA programs must be adjusted to individual physical abilities. Low-impact exercises like walking, swimming, and stretching are often effective. Involving physical therapists or specialized trainers can ensure a safe, gradual start, reducing the risk of quitting due to physical discomfort.

Logistical barriers include limited access to sports facilities, lack of money, and time constraints. Financial difficulties are severe for many, and transportation issues or distance from facilities can limit involvement. For those balancing treatment with work and family, time often restricts PA engagement. Home-based programs and activities that do not require expensive equipment, such as jogging or bodyweight exercises, can help. Using monitoring apps or exercise videos allows for flexible participation. For those with limited time, shorter, more frequent sessions throughout the day can still provide benefits.

Lack of social support is another critical barrier, as individuals with SUDs often experience isolation. This can reduce motivation and increase the risk of dropping out. Small support groups within PA programs can provide a safe space for sharing experiences and mutual encouragement. Family involvement, when possible, can also offer additional support. Finally, many do not fully grasp the benefits of PA in SUD treatment, seeing it as optional. Educating individuals through informative sessions, patient testimonials, and research findings can highlight PA as a crucial part of recovery. Regular monitoring and feedback, such as through fitness apps or healthcare provider check-ins, can also significantly boost motivation and adherence.

Recommendations and Practical Implications

This review emphasizes the important role of physical activity (PA) in treating and rehabilitating individuals with Substance Use Disorders (SUDs). Evidence shows that PA improves physical, mental, and behavioral outcomes. It is crucial to translate these findings into practical strategies for healthcare and community settings. A key recommendation is to create PA programs specifically for each individual, considering factors like the type of substance used, other health conditions, age, fitness level, and personal preferences. Tailored interventions improve adherence and lead to better treatment results.

PA should be systematically added to SUD treatment programs in both clinics and communities. Accessibility can be improved by offering affordable or free options, such as community walking groups or exercise plans for use at home. Healthcare facilities might also set aside funds for hiring exercise specialists or creating specific fitness areas to support these efforts. Sustained participation in PA programs can be supported through monitoring tools like wearable devices or mobile applications, which provide immediate feedback and boost motivation.

Improving how well individuals stick to PA programs is essential. This can be done by addressing common barriers such as lack of motivation, limited access, and insufficient social support. Starting with low-intensity activities and gradually increasing effort builds confidence and prevents overdoing it. Group programs can foster a sense of community, reduce feelings of loneliness, and increase accountability. Incentive systems, such as rewards for reaching milestones, can further encourage participation.

Healthcare providers have a vital role in promoting PA for SUD recovery. They should receive training on the benefits of PA and be ready to address patient concerns, such as physical limitations or doubts about its effectiveness. Additionally, adjusting PA programs to fit different cultures and contexts is crucial to ensure their relevance and acceptance. Incorporating traditional or local activities can increase engagement and acceptance among diverse populations.

To maintain these interventions over time, collaboration among healthcare systems, community organizations, and policymakers is necessary. Securing long-term funding and prioritizing PA as a preventive and therapeutic tool in SUD treatment can embed these programs into standard care practices. Ultimately, these efforts aim to make PA programs more accessible, improve adherence, and increase their effectiveness, significantly improving outcomes for individuals recovering from SUDs.

Future Research Directions and Importance of Longitudinal Studies

To further strengthen the evidence for physical activity (PA) as an additional therapy for Substance Use Disorders (SUDs), long-term clinical studies are essential. These studies are needed to track effects over time and fully understand how the amount of PA relates to patient outcomes. Such research should explore not only the immediate impacts of different PA types (like aerobic exercise, high-intensity interval training, or yoga) but also their lasting benefits, especially regarding preventing relapse and managing cravings.

It would also be valuable to test how PA combines with other treatments, such as Cognitive Behavioral Therapy (CBT) or medication, to evaluate the effectiveness of these integrated approaches in managing SUDs. Specifically, using digital technologies for tracking progress and personalizing programs could create new opportunities for improving treatments. Future research should also focus on adapting PA programs to different types of addiction (e.g., alcohol, various drugs, stimulants) and the specific physical and mental needs of individuals, leading to tailored treatment plans that maximize benefits and reduce relapse rates. Researchers should also address existing gaps by investigating potential negative effects of PA in populations with other mental health conditions, like bipolar disorder. Rigorous randomized controlled trials are necessary to reduce publication bias and provide a balanced understanding of both the benefits and risks of PA across different patient groups. Incorporating innovative technologies, such as virtual reality and biomarker monitoring, could further improve the safety and effectiveness of these interventions.

Study Limitations

While this review highlights the therapeutic potential of physical activity (PA) in Substance Use Disorders (SUDs), it is important to acknowledge its limitations. As a narrative review, it does not use a systematic method for collecting data, which could lead to bias in study selection. This is further complicated by including studies with varied methods and diverse populations, making it hard to apply findings broadly. Most evidence comes from small studies, which limits how widely the results can be applied in real clinical settings. The differences in PA interventions, including type, intensity, and duration, also make it challenging to draw consistent conclusions. Additionally, this review mainly focuses on PA's benefits, with limited exploration of potential negative effects or reasons not to use PA for specific patient groups. For example, individuals with bipolar disorder might experience mood instability from certain exercises. Research on biomarkers and new technologies in PA for SUDs is still new. While some promising studies have begun to look at using brain imaging and digital health tools to track treatment progress, these technologies are not yet widely used or proven in clinical settings. This gap shows the need for more long-term studies that use advanced technologies to provide objective and reliable data on PA interventions' long-term benefits and risks. Lastly, publication bias might be a concern, as studies with positive results are more often published, potentially distorting the perception of PA’s effectiveness. Comprehensive analyses that include unpublished and negative results could offer a more balanced understanding of PA’s role in SUD treatment.

Conclusions

Physical activity (PA) is a promising and potentially effective additional therapy for managing Substance Use Disorders (SUDs). It contributes to better mental health, improved quality of life, reduced cravings, and prevention of relapse. Evidence suggests that PA directly affects the brain, which is crucial for countering the long-term effects of substances and for finding specific markers of its effectiveness. Ongoing research and the use of new technologies are vital to improve the effectiveness and long-term viability of these therapeutic programs. The goal is to support more complete and lasting rehabilitation for individuals with SUDs.

The success of PA programs largely depends on overcoming barriers to participation, including physical, psychological, and practical obstacles. This involves boosting patient motivation and making PA more accessible. It also means organizing social and health services for addiction care to include PA, thereby meeting needs for health prevention and social integration. Exploring ways to adapt PA programs to different types of addiction and the specific physical and mental needs of individuals will help create personalized protocols. These protocols could maximize therapeutic benefits and significantly reduce relapse rates, supporting a comprehensive and sustainable approach to treatment.

Introduction

Substance Use Disorders (SUDs) present a significant challenge to global public health, affecting individuals, families, and communities profoundly. These disorders are characterized by chronic, relapsing patterns of compulsive substance use, often leading to severe physical, psychological, and social problems. The worldwide impact of SUDs continues to grow, increasing healthcare costs, disability rates, and societal inequalities.

While established treatments, such as medication and psychotherapy, have proven effective for many, they sometimes do not fully address all aspects of SUDs, particularly the connection between physical and mental health. High rates of relapse remain a concern, highlighting the need for new, comprehensive approaches that support lasting recovery. Recent advancements in understanding the brain and social factors involved in SUDs have increased interest in supportive therapies like physical activity (PA).

Physical activity offers a broad approach to recovery, influencing both brain function and behavior. Regular physical activity has been shown to improve the brain's ability to adapt and change (neuroplasticity) and to regulate the brain's reward system, which is often disrupted in individuals with SUDs. Research suggests that exercise can act as a new treatment for substance use, helping to ease withdrawal symptoms, reduce cravings, and improve mood by affecting dopamine levels and other brain chemicals.

Furthermore, studies indicate that physical activity positively influences anxiety and depression, conditions that frequently accompany SUDs. Addressing these co-occurring mental health issues is vital for successful recovery. For instance, exercise specifically designed for individuals with SUDs has been reported to improve physical health, mood, and overall well-being, underscoring its value as a holistic therapeutic tool. Animal studies have also provided insights into how physical activity benefits recovery, showing that voluntary exercise can lessen anxiety and seizure risk in substance-dependent animals, pointing to the brain-protective role of physical activity in addiction recovery. These findings lay the groundwork for exploring how physical activity interventions can enhance existing treatments and offer new ways to address the complexities of SUDs.

This review aims to assess the evidence supporting physical activity as an additional therapy for SUDs. It focuses on how physical activity affects the brain, its therapeutic benefits, and its practical use in clinical and community environments. By examining the connections among physical, psychological, and social factors, this review seeks to improve understanding of physical activity's role in promoting recovery and long-term well-being for individuals with SUDs. The review explores the neurobiological mechanisms through which physical activity benefits individuals with SUDs, discusses specific physical activity interventions and their effectiveness, and analyzes challenges to implementation, offering suggestions for integrating physical activity into treatment programs.

Results

Fifty studies met the criteria and were included in the final review. The findings were grouped by theme and discussed in detail, with a focus on barriers and strategies to improve adherence to physical activity, along with future research directions.

Neurobiological Mechanisms and Brain Plasticity

The positive effects of physical activity on Substance Use Disorders are supported by brain-based mechanisms involving dopamine and brain-derived neurotrophic factor (BDNF), both essential for the brain's ability to change and adapt. Physical activity is thought to adjust dopamine signaling in the brain, encouraging brain adaptations that help counteract the effects of substances. Exercise positively impacts brain circuits related to reward and pleasure, shown by observations of increased endorphins and improved mood in individuals with SUDs. Additionally, physical activity reduces the stress hormone cortisol, supporting healthier stress regulation and helping to reduce anxiety, which is a common trigger for relapse. The normalization of dopamine and glutamate activity facilitated by exercise may also assist in long-term relapse management.

An important area in physical activity research is identifying brain markers that can predict an individual's response to exercise. Understanding the genetic, epigenetic, and molecular factors behind individual differences in how exercise affects brain plasticity could help create personalized physical activity programs for the best therapeutic results. Brain imaging techniques, such as functional magnetic resonance imaging (fMRI), could also be used to observe real-time changes in brain activity and structure during exercise, providing deeper insights into how physical activity influences brain function in patients with SUDs.

Effects on Abstinence and Craving Symptoms

One of the most studied effects of physical activity in SUDs is its ability to lessen cravings and withdrawal symptoms. A review of multiple studies showed that moderate and intense physical activity programs can significantly increase rates of abstinence. Positive effects were also observed on physical and psychological withdrawal symptoms, such as irritability, insomnia, and anxiety. Long-term studies indicate that physical activity contributes to lower relapse rates both in the early stages of recovery and over longer periods, suggesting a lasting impact on maintaining abstinence.

Benefits of Mental Health and Quality of Life

Physical activity is linked to significant improvements in mental health and overall quality of life for individuals with SUDs. Interventions based on physical activity, such as aerobic exercises and yoga, have been reported to reduce symptoms of depression and anxiety, improve mood, and decrease the likelihood of relapse. One study showed that a group aerobic exercise program improved cognitive functions and emotions in individuals with SUDs.

These effects are believed to result from increased levels of endorphins and serotonin, which can enhance emotional well-being. Mind-body practices like Tai Chi have also proven effective in improving emotional regulation, thereby building psychological resilience.

Differences Among Types of Physical Activity and Their Efficacy in SUDs

The type and intensity of physical activity play a crucial role in treating Substance Use Disorders. Aerobic exercises, such as running and cycling, help reduce cravings for stimulants like cocaine by boosting dopamine and serotonin levels. Mind-body activities like yoga and Tai Chi improve emotional regulation and reduce anxiety, making them effective for opioid and alcohol dependencies. High-intensity interval training (HIIT) shows promise for restoring brain plasticity due to increased BDNF levels but requires careful supervision. A personalized approach that adapts physical activity to an individual's needs and recovery stage is essential for achieving the best treatment outcomes.

Discussion

Physical activity offers numerous psychological benefits for individuals with Substance Use Disorders that are essential for supporting the recovery process. These benefits include increased resilience, improved self-efficacy, stronger emotional regulation, and a general reduction in stress and anxiety. These factors are crucial for managing addiction and preventing relapse. Regular physical activity helps individuals develop healthier coping mechanisms for stressors, increasing their confidence in their ability to maintain abstinence and face daily challenges without returning to substance use. Physical activity also positively impacts mood and energy, enhancing an individual's intrinsic motivation to stay abstinent and reducing symptoms of anhedonia and apathy often associated with SUDs. Furthermore, physical activity can improve sleep quality, which is frequently disrupted in individuals with SUDs, thereby contributing to overall well-being and reducing relapse risk.

From a neurobiological perspective, physical activity enhances neuroplasticity, which is the brain's capacity to reorganize itself by forming new connections. This process is vital for recovery because substance use often alters the brain's reward system, including dopamine pathways and areas like the prefrontal cortex and nucleus accumbens. These changes lead to problems with reward processing and increase vulnerability to cravings, stress, and relapse. Physical activity, particularly moderate to intense aerobic exercise, helps reverse these changes by promoting the release of brain-derived neurotrophic factor (BDNF), which facilitates the growth of new neurons and synapses. It also helps restore balance in the dopaminergic system, increasing dopamine receptor sensitivity and dopamine release, thereby re-establishing healthier reward circuits.

Beyond dopamine and BDNF, physical activity also influences the endocannabinoid system (ECS), which regulates mood, pain, reward, and stress, and plays a role in how the brain responds to addictive substances. Exercise increases endocannabinoid levels, which can reduce stress and anxiety and lessen cravings. This mechanism is particularly relevant for individuals recovering from SUDs, as dysregulated stress responses and heightened anxiety are common triggers for relapse. Physical activity also helps regulate the hypothalamic-pituitary-adrenal (HPA) axis, which is often overactive in chronic substance use, leading to high cortisol levels and impaired emotional regulation. By normalizing the HPA axis, physical activity helps reduce vulnerability to relapse. These brain changes support both cognitive recovery and emotional resilience.

The choice of physical activity type and intensity is critical for effective SUD treatment. Aerobic exercises like running, walking, swimming, and cycling are effective for stimulant dependencies, as they boost neurotransmitters like dopamine and serotonin, helping to counteract cravings and improve mood. Mind-body activities such as yoga and Tai Chi are particularly beneficial for opioid and alcohol dependencies, as they improve emotional regulation and reduce anxiety by combining physical movement with breathing and mindfulness. High-intensity interval training (HIIT) shows promise for enhancing neuroplasticity due as it increases BDNF levels, but it requires careful monitoring. Emerging tools like biomarkers and advanced technologies, such as functional magnetic resonance imaging (fMRI), virtual reality (VR), and augmented reality (AR), are also being explored to personalize interventions and monitor brain adaptations during physical activity-based rehabilitation.

Ultimately, the optimal approach involves tailoring physical activity programs to the individual's specific needs, type of substance dependence, and recovery stage. An adaptive approach, where individuals gradually progress from lower-intensity mind-body activities to higher-intensity programs, can maximize therapeutic effectiveness. Combining physical activity with other therapies, such as Cognitive Behavioral Therapy (CBT) or pharmacological treatments, can lead to more robust outcomes in preventing relapse and supporting long-term recovery by addressing both the physiological and psychological aspects of addiction. However, it is important to acknowledge that publication bias exists in the research, with a tendency to report positive outcomes more often, potentially understating limitations or adverse effects, particularly for individuals with co-occurring psychiatric conditions.

Limitations of the Current Literature

Research on physical activity in Substance Use Disorder rehabilitation has provided valuable insights, but certain limitations exist. A major issue is the inconsistency in study methods, including variations in physical activity types, intensities, and durations, which makes direct comparisons difficult and hinders the development of standard treatment guidelines. Many studies rely on self-reported data for physical activity adherence and outcomes, which can lead to inaccuracies and overestimations of benefits due to recall bias.

Another limitation is the lack of diverse populations in research samples. Most studies focus on similar groups, often excluding individuals with co-occurring mental health conditions or severe physical limitations, despite these conditions being common in SUD populations. Furthermore, there is insufficient evidence on the potential negative effects of physical activity, especially for vulnerable groups. For example, individuals with bipolar disorder, who may share some brain similarities with SUDs, could experience mood instability from certain types of exercise. The use of biomarkers and advanced technologies in physical activity research for SUDs is also still in its early stages. While promising studies have begun to use neuroimaging and digital health tools to track treatment progress, these technologies are not yet widely adopted or clinically validated. This highlights the need for more long-term studies that integrate advanced technologies to provide objective and reliable data on the sustained benefits and risks of physical activity interventions.

Finally, publication bias may be a concern, as studies with positive results are more likely to be published, potentially skewing the perception of physical activity's effectiveness. Comprehensive analyses that include unpublished or null-result studies could provide a more balanced understanding of physical activity's role in SUD treatment.

Materials and Methods

A literature search was conducted on 30 September 2024, using major online academic databases including PubMed, Web of Science, Google Scholar, and Scopus. To ensure a thorough review of the literature for this narrative review, specific keywords were used for each thematic area. These search terms were combined using Boolean operators (AND, OR) to effectively narrow down the results.

Search Strategy

The keywords used in the search strategy included: "physical activity," "exercise," "substance use," "substance use disorder," "addiction," "rehabilitation," "therapy," "recovery," "treatment outcomes," and "addiction recovery" for the general topic. For neurobiological mechanisms, terms like "dopamine," "reward system," "brain plasticity," "neurotransmitters," "endogenous opioids," "stress regulation," "neurobiological changes," "craving reduction," "executive function," and "neuroadaptation" were used. Psychological benefits were explored using "stress management," "mood enhancement," "self-esteem," "anxiety reduction," "depression management," "coping mechanisms," "psychological resilience," "behavioral activation," and "emotional regulation." Social benefits were investigated with "social support," "community engagement," "peer support," "social integration," "group exercise," "team sports," and "social networks," and "isolation reduction." For intervention studies and effectiveness, keywords included "clinical trials," "intervention studies," "effectiveness," "outcomes," "exercise programs," "structured physical activity," "randomized controlled trials," and "observational studies." Comparative approaches used terms such as "physical activity vs. traditional therapies," "multimodal approaches," "combined interventions," "exercise and pharmacotherapy," and "alternative treatments," "comparative effectiveness." Studies published from 1988 to 2024 and written in English were considered.

Inclusion and Exclusion Criteria

The inclusion criteria for the review were randomized clinical trials, cohort studies, reviews, and meta-analyses that focused on physical activity in substance use disorder rehabilitation. Exclusion criteria included single case reports with limited clinical relevance and studies that focused only on pharmacological or psychotherapeutic treatments, or alternative treatments without integrating physical activity. Abstracts, conference proceedings, and articles without full text availability were also excluded.

Data Extraction

Initial screening involved reviewing titles and abstracts by the first author. Full-text articles were then reviewed based on the inclusion criteria. The most relevant articles were selected according to the research focus, which included the neurobiological mechanisms underlying the effect of physical activity on SUD rehabilitation, its effects on abstinence and craving, its impact on quality of life and mental health, the search for neurobiological markers, and the differences among various types of exercise and psychoactive substances. Any disagreements were resolved through discussion among the authors.

Barriers to Participation and Strategies to Enhance Adherence

Despite the proven benefits, many individuals with Substance Use Disorders encounter difficulties in maintaining their commitment to physical activity. These challenges often stem from insufficient facilities, a lack of social support, and diminished motivation. Research suggests that these barriers can be physical, psychological, social, and logistical, each requiring specific interventions to encourage consistent participation. Addressing these diverse obstacles is crucial for promoting sustained engagement in physical activity programs and improving treatment outcomes for SUDs.

Psychological barriers include low motivation, poor self-esteem, and social anxiety. Individuals in recovery often experience symptoms of depression and apathy, which can severely reduce their desire to engage in physical activity. Low self-esteem can lead to avoidance of exercise due to fears of inability or judgment. High social anxiety among individuals with SUDs can also make them feel vulnerable in public or group settings, deterring participation. To overcome these, psychological support and encouragement of self-efficacy are vital. Orientation sessions can help individuals set realistic goals and personalize programs, reducing anxiety and building confidence. Starting with low-intensity exercises in private or individual settings can ease individuals into programs. Motivation techniques like tracking progress and providing positive reinforcement also enhance self-efficacy. Group-based interventions or mindfulness activities like yoga can address stigma and lack of awareness, fostering a supportive community.

Physical barriers frequently arise from chronic health conditions caused by prolonged substance use, such as cardiovascular issues, respiratory problems, and muscle pain, which limit intense physical activity. Physical withdrawal symptoms, like fatigue and weakness, can also impede regular participation, especially during the initial months of treatment. To address these, physical activity programs must be tailored to an individual's physical capabilities. Low-impact exercises, such as walking, swimming, and stretching, are effective for improving fitness without excessive strain. Involving physical therapists or specialized trainers can help individuals start safely with a gradual, supervised program adapted to their physical limitations, reducing the risk of dropout due to physical difficulties.

Logistical barriers include limited access to sports facilities, financial constraints, and time limitations. Many individuals recovering from addiction face financial difficulties or lack transportation to facilities. Balancing treatment with work and family commitments can also make finding time for physical activity challenging. To reduce these barriers, home-based programs and activities that do not require expensive equipment or specific venues, like jogging or bodyweight exercises, can be promoted. Monitoring apps and exercise video guides offer flexible home-based options. For those with time constraints, shorter sessions spread throughout the day can accumulate benefits.

Finally, a lack of social support and insufficient awareness of physical activity's benefits are significant obstacles. Individuals with SUDs often experience isolation or have limited social networks, reducing their motivation and increasing dropout risk. To counter this, small support groups within physical activity programs can provide a safe space for shared experiences and mutual encouragement. Family involvement, where possible, can also offer additional support. Education about physical activity's specific benefits, such as reducing cravings and improving mood, should be integrated into treatment programs through informative sessions and testimonials. Furthermore, a consistent monitoring and feedback system, perhaps using fitness applications or wearable devices, can provide immediate feedback on progress, boosting motivation and adherence. Regular feedback from healthcare providers also significantly improves long-term commitment.

Recommendations and Practical Implications

This review highlights the critical role of physical activity in treating and rehabilitating individuals with Substance Use Disorders. Evidence shows that physical activity improves physical, psychological, and behavioral outcomes. Translating these findings into practical strategies for clinical and community settings is essential.

A key recommendation is to customize physical activity programs to individual characteristics, such as the type of substance used, co-occurring conditions, age, fitness level, and personal preferences. Personalized interventions enhance adherence and optimize therapeutic results. For instance, activities like yoga or walking may suit those with physical limitations, while running or strength training might be better for individuals seeking greater physical challenges. Physical activity should also be integrated into comprehensive treatment approaches, combining it with therapies like cognitive-behavioral therapy or medication. Such combined approaches address both the physiological and psychological aspects of recovery, promoting a holistic path for individuals. Sustained engagement can be supported through monitoring mechanisms, such as wearable devices or mobile applications, which provide real-time feedback and reinforce motivation.

In practical terms, physical activity should be systematically included in SUD treatment programs across both clinical and community settings. Accessibility can be improved by offering low-cost or free options, such as community walking groups or home-based exercise plans. Facilities may need to allocate resources for hiring exercise specialists or creating dedicated fitness spaces. To enhance adherence, common barriers like lack of motivation, limited access, and insufficient social support must be addressed. Starting with low-intensity activities and gradually increasing intensity builds confidence and prevents overexertion. Group-based programs can foster a sense of community, reduce isolation, and improve accountability, while incentive systems can further encourage participation. Healthcare providers play a crucial role in promoting physical activity for SUD recovery; they should receive training on its benefits and be prepared to address patient concerns, such as physical limitations or skepticism.

Additionally, cultural and contextual adaptations are essential to ensure the relevance and acceptance of physical activity programs. Incorporating traditional or region-specific activities can enhance engagement and foster greater acceptance among diverse populations. Sustaining these interventions requires collaboration among healthcare systems, community organizations, and policymakers. Establishing long-term funding and prioritizing physical activity as a preventive and therapeutic tool in SUD treatment can embed these programs into standard care practices. Ultimately, these efforts promise to enhance the accessibility, adherence, and effectiveness of physical activity programs, significantly improving outcomes for individuals recovering from SUDs.

Future Research Directions and the Importance of Longitudinal Clinical Studies

To further solidify the effectiveness of physical activity as an additional therapy for Substance Use Disorders, long-term clinical studies are crucial. These studies are needed to monitor sustained effects and fully understand the relationship between different amounts of physical activity and patient outcomes. Such research should explore not only the immediate impacts of various physical activity methods (aerobic, high-intensity interval training, yoga, etc.) but also their long-term benefits, especially concerning relapse prevention and craving management.

It would also be valuable to test how physical activity integrates with other treatment approaches, such as Cognitive Behavioral Therapy or medication, to evaluate the effectiveness of combined strategies in managing SUDs. Specifically, using digital technologies for tracking progress and personalizing programs could create new opportunities for optimizing treatments. Future research should also focus on adapting physical activity programs to different types of addiction (e.g., alcohol, specific drugs, stimulants) and to the unique physical and psychological needs of individuals, developing tailored therapeutic protocols that maximize benefits and reduce relapse rates.

Future research should also aim to fill gaps in current literature by investigating potential negative effects of physical activity in populations with co-occurring psychiatric conditions, such as bipolar disorder. Rigorous randomized controlled trials are necessary to reduce publication bias and provide a balanced understanding of both the benefits and risks of physical activity in diverse patient groups. Additionally, studies should explore personalized approaches that adapt physical activity regimens to the unique needs of individuals with co-occurring mental health conditions. Integrating innovative technologies, such as virtual reality and biomarker monitoring, could further enhance the safety and effectiveness of these interventions.

Study Limitations

While this review highlights the therapeutic potential of physical activity in Substance Use Disorders, it is important to acknowledge its limitations. As a narrative review, it does not use a systematic approach to data collection, which could introduce selection bias. This limitation is compounded by the inclusion of studies with varied methods and diverse populations, making it challenging to generalize findings. Additionally, most of the evidence comes from small-scale studies, which limits how broadly the findings can be applied in clinical settings. The variability in physical activity interventions, including differences in type, intensity, and duration, further complicates drawing consistent conclusions.

Furthermore, the review primarily focuses on the benefits of physical activity, with limited exploration of potential negative effects or reasons why it might not be suitable for specific patient groups. For example, individuals with bipolar disorder, who may have some similar neurobiological features to those with SUDs, could experience mood instability from certain types of exercise. Moreover, the investigation of biomarkers and innovative technologies in physical activity research for SUDs is still in its early stages. While promising studies have begun to examine the use of neuroimaging and digital health tools for tracking treatment progress, these technologies are not yet widely adopted or validated in clinical settings. This gap highlights the need for more long-term studies that integrate advanced technologies to provide objective and reproducible data on the sustained benefits and risks of physical activity interventions.

Finally, publication bias may be a concern, as studies with positive results are often more likely to be published, potentially skewing the perception of physical activity's effectiveness. Comprehensive analyses that include unpublished and null-result studies could provide a more balanced understanding of physical activity's role in SUD treatment.

Conclusions

Physical activity is a promising and potentially effective additional therapy for managing Substance Use Disorders, contributing to improved mental health and quality of life, reduced craving symptoms, and prevention of relapse. Evidence suggests that physical activity directly affects the brain in ways that are crucial for counteracting the chronic effects of substances and for developing specific markers of effectiveness. The ongoing evolution of research and the application of innovative technologies are essential for improving the effectiveness and sustainability of these therapeutic programs, with the goal of promoting more comprehensive and lasting rehabilitation for individuals with Substance Use Disorders.

The success of physical activity programs largely depends on overcoming barriers that limit adherence, including physical, psychological, and logistical obstacles, thereby boosting motivation and accessibility. This also means organizing social and health services for addiction care to consider this evidence, thus meeting the needs for health prevention and social integration.

Exploring ways to adapt physical activity programs to different types of addiction and to the specific physical and psychological needs of individuals will pave the way for personalized protocols. These protocols could maximize therapeutic benefits and significantly reduce relapse rates, contributing to a holistic and sustainable therapeutic approach.

Introduction

Substance Use Disorders (SUDs) present a major public health challenge worldwide, affecting individuals, families, and communities. These disorders are described as long-term conditions involving a strong urge to use substances, often leading to serious problems with a person's physical and mental health, as well as their social life. The global impact of SUDs continues to grow, increasing healthcare costs, disability rates, and inequalities across societies.

While common treatments like medication and talk therapy have helped many, they sometimes do not address all parts of SUDs, especially how physical and mental health are connected. High rates of relapse remain a concern, highlighting the need for new and complete approaches that support long-term recovery. Recent discoveries about how SUDs affect the brain and behavior have led to interest in complementary therapies, such as physical activity (PA), as a broader part of treatment.

Regular physical activity offers many benefits for recovery, impacting both brain function and behavior. Research indicates that exercise helps the brain adapt and changes the brain's reward system, which often does not work properly in individuals with SUDs. Studies suggest that exercise can serve as a new way to treat addiction by easing withdrawal symptoms, reducing cravings, and improving mood. This happens because exercise affects dopamine levels and other brain chemicals. Physical activity also helps with anxiety and depression, which often occur alongside SUDs, tackling important related health issues that can hinder recovery. Animal studies have further shown that voluntary exercise can lessen anxiety and lower the risk of seizures during addiction recovery. These findings lay the groundwork for exploring how physical activity can supplement current treatments and offer new ways to address the complex nature of SUDs.

This review aims to examine the evidence that supports physical activity as an additional therapy for SUDs. It focuses on how PA affects the brain, its treatment benefits, and how it can be used in clinics and communities. By looking at how physical, mental, and social factors interact, this review seeks to improve understanding of PA's role in helping individuals with SUDs recover and maintain long-term well-being.

The review is structured to first explore how physical activity benefits the brains of individuals with SUDs. Next, it discusses specific PA programs and how well they work in different situations. Finally, it looks at obstacles to putting these programs into practice and suggests ways to include physical activity in clinical and community settings.

Results

Fifty studies were included in this review. The findings were organized by theme and further discussed, with attention to barriers and ways to improve participation in physical activity and future research needs.

Neurobiological Mechanisms and Brain Plasticity

The positive effects of physical activity on SUDs are supported by how it influences the brain, particularly through dopamine and brain-derived neurotrophic factor (BDNF), both of which are essential for the brain's ability to change and adapt. Researchers suggest that physical activity changes the brain's dopamine system, leading to brain adaptations that help counteract the effects of substances. Exercise also positively affects the brain's reward and pleasure circuits, leading to improved mood. Additionally, physical activity lowers cortisol, a stress hormone, which helps regulate stress more effectively and reduces anxiety, a known trigger for relapse. Furthermore, exercise can help normalize brain activity related to dopamine and other chemicals, which may assist in long-term relapse management.

An exciting area of research in physical activity is looking for brain markers that can predict how someone will respond to exercise. Understanding the genetic and molecular factors behind individual differences in how exercise changes the brain could help create personalized physical activity programs for the best treatment results. Brain imaging techniques could also be used to observe real-time changes in brain activity and structure during exercise, offering deeper insights into how physical activity affects the brains of individuals with SUDs.

Effects on Abstinence and Craving Symptoms

One of the most studied effects of physical activity in SUDs is its ability to reduce cravings and withdrawal symptoms. A large analysis of many studies showed that moderate and intense physical activity programs can significantly increase the number of individuals who remain abstinent. Positive effects were also seen on physical and mental withdrawal symptoms, such as irritability, sleeplessness, and anxiety. Long-term studies indicate that physical activity helps reduce relapse rates both in the early stages of recovery and over longer periods, suggesting a lasting impact on staying sober.

Benefits of Mental Health and Quality of Life

Physical activity is linked to major improvements in mental health and overall quality of life for individuals with SUDs. Interventions that include physical activity, such as aerobic exercises and yoga, have been reported to lessen symptoms of depression and anxiety, improve mood, and decrease the chance of relapse. One study showed that a group aerobic exercise program improved thinking skills and emotions in individuals with SUDs. These positive effects are believed to come from increased levels of endorphins and serotonin, which can boost emotional well-being. Mind-body exercises like Tai Chi have also proven effective in improving emotional control, thereby increasing mental toughness.

Differences Among Types of Physical Activity and Their Efficacy in SUDs

The type and intensity of physical activity are very important in treating SUDs. Aerobic exercises such as running and cycling can help reduce cravings for stimulants like cocaine by increasing dopamine and serotonin levels. Mind-body activities like yoga and Tai Chi improve emotional control and reduce anxiety, making them helpful for those dependent on opioids and alcohol. High-intensity interval training (HIIT) shows promise for helping the brain recover its ability to change due to increased levels of certain brain chemicals, but it requires careful supervision. A treatment approach that is custom-made to each person's needs and stage of recovery is essential for the best results.

Discussion

Beyond its physical effects, physical activity offers many mental benefits for individuals with SUDs that are crucial for supporting recovery. These benefits include stronger resilience, greater self-confidence, better emotional control, and a general reduction in stress and anxiety, all of which are vital for managing and preventing relapse.

Resilience, which is the ability to handle difficulties and adapt well to stressful situations, is essential for those trying to overcome addiction. Studies show that physical activity can help build and strengthen resilience, improving a person's ability to manage the mental challenges that come with withdrawal. This helps individuals become more resilient to stress and develop healthier ways of coping that do not involve substance use. The resilience gained through physical activity is not just a short-term effect; long-term studies suggest that as individuals continue regular physical activity, their resilience tends to become more solid. This is especially important for preventing relapse, as resilience helps individuals navigate high-risk situations without returning to harmful behaviors.

Physical activity also helps improve self-confidence, which is a person's belief in their ability to perform specific actions to achieve certain outcomes. Physical activity requires discipline, specific goals that can be measured, and gradual improvements in performance, all of which build self-confidence. During recovery, individuals with high self-confidence are more likely to believe they can stay abstinent and handle daily challenges without turning to substance use. Physical activity allows individuals to see real progress, such as better endurance or physical strength. This can easily lead to a broader sense of their capabilities, including control over their addiction. Step-by-step exercise programs, where small, achievable goals are set, boost self-confidence and increase motivation, empowering individuals to feel in charge of their recovery.

One of the most immediate and well-known mental benefits of physical activity is its ability to reduce anxiety and stress, which are common and worsening factors in SUDs. Anxiety can increase the risk of relapse and is often a main reason individuals return to substances. Physical activity helps lower cortisol levels (the stress hormone) and boosts endorphin release. Mind-body activities like yoga and Tai Chi have been effective in reducing anxiety levels in individuals with SUDs. These activities combine physical movement with breathing and mindfulness, leading to deep relaxation. Such exercises not only improve a person's emotional state in the short term but also increase their awareness of their emotional responses, promoting more effective stress management.

Physical activity can also improve emotional regulation, helping individuals respond to stressful situations in healthier ways instead of using substances to cope. Activities like jogging, brisk walking, and low-impact aerobics have been linked to reduced impulsivity and better emotional control. Additionally, mindfulness training through activities such as yoga can help individuals become more aware of their emotions and physical sensations, reducing impulsive actions and encouraging a calmer, more thoughtful response to daily challenges. This is especially helpful for individuals with alcohol or opioid dependencies, who often struggle with emotional regulation and face a higher risk of relapse during stressful times. Physical activity, by positively affecting mood and energy, can also boost a person's inner drive to stay abstinent. Individuals who include physical activity in their treatment programs often report higher motivation to continue their recovery journey and maintain a healthy lifestyle. Physical activity not only makes individuals more proactive but also lessens feelings of anhedonia (inability to feel pleasure) and apathy, which are common symptoms of depression associated with SUDs. By acting as a natural antidepressant, physical activity stimulates the release of positive brain chemicals and encourages the growth of new brain cells, counteracting depressive symptoms and reducing the likelihood of relapse during times of low mood and isolation. Another indirect mental benefit of physical activity is improved sleep quality. Sleep problems are common among individuals with SUDs, as long-term substance use can disrupt natural sleep patterns and reduce sleep quality. Poor sleep increases the risk of relapse, leaving individuals more vulnerable and less able to cope with stress. Physical activity, particularly aerobic exercises, has been shown to improve sleep quality, contributing to overall physical and mental well-being and reducing the risk of relapse.

Regarding how physical activity affects the brain, neuroplasticity is the brain's ability to reorganize itself by forming new connections in response to learning, experiences, or changes in the environment. This process is crucial for recovery in individuals with SUDs, as substance use often changes the brain's reward system, particularly areas involved in dopamine pathways. These changes lead to problems with reward processing and make individuals more prone to cravings, stress, and relapse. The positive effects of physical activity on SUDs are supported by brain mechanisms involving dopamine and brain-derived neurotrophic factor (BDNF), both vital for the brain's ability to change. BDNF helps grow new brain cells and connections, especially in areas vulnerable to damage from substance use. Physical activity, especially moderate to intense aerobic exercise, has been shown to improve brain function by increasing BDNF release and strengthening connections in key brain areas. Studies indicate that physical activity reduces cravings by lowering the overactivity of brain regions linked to reward processing. These changes are important for preventing relapse, as the ability to manage emotions and make good decisions is essential for staying abstinent and resisting the urge to use substances. Drugs of abuse often cause a huge surge of dopamine in the brain's reward centers, creating feelings of pleasure and reinforcing addictive behavior. Over time, however, the brain's natural reward system becomes less responsive, requiring more of the substance to achieve the same effect. This problem with dopamine regulation contributes to the compulsive nature of addiction. Exercise has been shown to bring balance back to the dopamine system, especially by improving dopamine receptor sensitivity and releasing dopamine. Regular physical activity helps rebuild healthier reward circuits by increasing dopamine activity. Physical exercise positively affects brain circuits linked to reward and pleasure, improving mood.

Another new aspect of physical activity's brain effects is its influence on the endocannabinoid system (ECS), which helps regulate mood, pain, reward, and stress. The ECS is crucial in how the brain responds to addictive substances and is involved in both the reinforcing and anti-reward effects of drugs. Physical activity has been found to increase levels of certain endocannabinoids, which bind to receptors in the brain, especially in areas related to stress and emotional regulation. Exercise-triggered activation of the ECS may explain why individuals who exercise often report less stress and anxiety, as well as its role in reducing cravings. This mechanism is especially important for individuals recovering from SUDs, as poorly regulated stress responses and heightened anxiety are common triggers for relapse. These mechanisms also highlight PA's potential to reduce stress-related relapse triggers and improve emotional regulation, particularly in people with high anxiety or co-occurring post-traumatic stress disorder (PTSD). By changing the ECS, physical activity not only supports emotional stability but may also lessen the negative emotional states that often come with withdrawal and recovery.

One of the most powerful ways physical activity affects brain function is through its impact on stress-related pathways. Long-term substance use leads to an overactive stress response system, resulting in higher cortisol levels, which impairs emotional regulation and makes individuals more vulnerable to relapse. Furthermore, physical activity can work well with other therapies, such as Cognitive Behavioral Therapy (CBT), by improving cognitive and emotional control. The combined effects of physical activity and talk therapies may lead to stronger results in preventing relapse and supporting long-term recovery. Importantly, the brain-changing effects of physical activity are not limited to short-term improvements; the brain's capacity for change remains dynamic and continues to develop with ongoing exercise over time, offering continuous benefits for individuals in recovery. Additionally, promoting brain adaptation through mechanisms like increased levels of brain-derived neurotrophic factor (BDNF) not only helps with cognitive recovery but also supports emotional resilience. These changes emphasize the importance of including exercise in SUD therapy to address both the physical and mental aspects of recovery.

In recent years, there has been increasing interest in using biomarkers and new technologies to make SUD treatment programs more effective and sustainable. Using biomarkers like brain-derived neurotrophic factor (BDNF) and dopamine activity levels has shown promise in customizing physical activity programs to get the best brain-related benefits. Additionally, new tools like functional magnetic resonance imaging (fMRI) and neurofeedback systems allow for real-time tracking of brain changes during physical activity-based recovery, offering insights into how individuals respond differently to treatment. Beyond brain biomarkers, advanced technologies such as virtual reality (VR) and augmented reality (AR) are being explored as additional tools in SUD rehabilitation. These technologies create immersive environments that can simulate real-world triggers, allowing individuals to practice healthy responses while being physically active. For example, VR-based programs have been effective in reducing cravings and improving emotional regulation by combining mental strategies with physical engagement. Including these innovations in physical activity programs can help tailor interventions to individual needs, improve participation, and provide flexible solutions for diverse patient groups. Future studies should focus on testing these tools in clinical settings, evaluating their long-term impact on relapse prevention, and integrating them with traditional therapies for a complete recovery model.

Regarding the choice of physical activity type and its intensity, studies show that it can play a vital role in the effectiveness of SUD treatment. Recent research highlights how certain types of physical exercise may have specific effects depending on the type of addiction, the patient's recovery stage, and any co-occurring mental health issues. Aerobic exercises, such as running, brisk walking, swimming, and cycling, are among the most studied activities for their impact on SUDs, especially for stimulant addictions like cocaine and methamphetamines. These exercises are known for their ability to promote the release of brain chemicals like dopamine, serotonin, and endorphins, all key to counteracting cravings for substances and improving mood. Some studies suggest that aerobic exercise can imitate the dopamine surge typically caused by drugs, providing a positive effect that helps reduce cravings and the risk of relapse. Researchers reported a reduction in craving symptoms among methamphetamine-dependent participants after a 12-week moderate-intensity exercise program. This effect was accompanied by improved working memory, suggesting that better cognitive function may contribute to better craving management and increased self-control.

Another benefit of aerobic exercises is their flexibility and accessibility; individuals can practice them in gyms or outdoors. Additionally, their intensity can be adjusted based on a person's physical abilities and motivation, allowing for a personalized program that improves participation. However, high-intensity aerobic exercises may not be suitable for individuals with existing heart conditions or mobility issues, so choosing the right intensity and duration for each person is important. Mind-body activities, such as yoga, Tai Chi, and Qi Gong, are becoming particularly useful complementary tools for opioid and alcohol dependencies. These exercises focus not only on physical movement but also on body awareness and breath regulation, making them ideal for helping individuals develop better emotional management and greater awareness of their internal body sensations. Recent studies show that mind-body activities can reduce cortisol and promote a sense of calm and well-being. This effect is especially helpful for individuals with SUDs who are also dealing with anxiety and PTSD, which are often present in opioid dependencies. In addition to boosting mental resilience, mind-body activities improve self-control, a crucial quality for avoiding relapse. Since many individuals with SUDs tend to react impulsively to craving triggers, exercises like yoga and Tai Chi can teach techniques for managing responses, helping to reduce impulsivity and react more calmly to stress. It has been observed that individuals participating in yoga programs for several weeks show reduced craving scores and improved sleep quality, another factor that can help prevent relapse.

Although less studied in relation to SUDs compared to aerobic and mind-body exercises, high-intensity interval training (HIIT) programs are gaining interest for their potential to improve physical endurance and stimulate significant brain changes, such as increased levels of brain-derived neurotrophic factor (BDNF), which can support brain adaptation and recovery of brain areas damaged by long-term substance use. The benefit of HIIT programs for individuals with SUDs appears to be in their ability to stimulate a quick hormonal response, promoting stress resilience and improving tolerance for physical and mental discomfort. However, their high intensity may not be suitable for all individuals, especially those with heart conditions or severe mental health issues. Nonetheless, when properly supervised, HIIT programs could offer unique benefits for individuals who want an intensive recovery path and are in good physical condition.

Given the various effects of different types of physical activity on SUDs, the best treatment approach should be personalized, considering both the substance of dependence and the person's physical and mental characteristics. For example, for individuals with alcohol and opioid dependencies, who often experience anxiety and post-traumatic stress symptoms, mind-body activities may be particularly effective for long-term management. In contrast, for stimulant dependencies, where craving is a major issue, regular aerobic exercises may be more effective in safely mimicking the brain effects of substances, reducing the desire for use. A further benefit of a personalized approach is that physical activities can be adjusted to changes in a person's health and mental needs throughout recovery. Evidence suggests that an adaptable approach, where individuals start with mind-body activities and move to higher-intensity programs as they gain strength and resilience, could improve the treatment effectiveness of physical activity in SUDs. Moreover, there is growing interest in combining physical activity with other advanced therapies, such as brain stimulation techniques and medication, to enhance brain adaptation and further support recovery.

Despite the promising evidence on the benefits of physical activity in SUD rehabilitation, a common issue in this field is publication bias. Studies mostly focus on the positive outcomes of physical activity, possibly not reporting enough on negative effects or limitations. This bias might lead to an overly positive view of physical activity as a treatment, without properly addressing the risks for certain mental health conditions. For instance, in individuals with bipolar disorder, physical activity might trigger manic or hypomanic episodes, especially with high-intensity routines. Considering the similar brain mechanisms between SUDs and bipolar disorder, such as dopamine problems, more research is needed to evaluate the safety and suitability of physical activity for these groups.

Limitations of the Current Literature

The research on physical activity in the recovery of individuals with Substance Use Disorders has provided important insights, but certain limitations must be recognized. One significant problem is the variety in study methods, including differences in types, intensities, and durations of physical activity. This makes direct comparisons difficult and complicates the creation of standard treatment plans. Many studies rely on self-reported information about physical activity participation and results, which can lead to errors in memory and an overestimation of benefits.

Another limitation is that diverse populations are not well represented in research samples. Most studies focus on similar groups, often leaving out individuals with co-occurring mental health conditions or severe physical limitations, despite these issues being common in SUD populations. Furthermore, there is not enough strong evidence in the literature about the possible negative effects of physical activity, especially for vulnerable groups. For example, individuals with bipolar disorder, who may have some brain similarities to those with SUDs, could experience unstable moods from certain types of exercise. Additionally, the use of biomarkers and new technologies in physical activity research for SUDs is still in its early stages. While promising studies have started to explore brain imaging and digital health tools for tracking treatment progress, these technologies are not yet widely used or proven in clinical settings. This gap shows the need for more long-term studies that include advanced technologies to provide objective and repeatable data on the long-term benefits and risks of physical activity interventions.

Lastly, publication bias might be a concern, as studies with positive results are more likely to be published, potentially skewing the perception of physical activity's effectiveness. Comprehensive analyses that include unpublished and neutral findings could provide a more balanced understanding of physical activity's role in SUD treatment.

Materials and Methods

Search Strategy

A search was conducted on 30 September 2024, using major online academic databases including PubMed, Web of Science, Google Scholar, and Scopus. To ensure a thorough review of the literature, specific keywords were used for each thematic area of the study. These search terms were combined using logical operators like "AND" and "OR" to refine the results. Keywords included terms related to "physical activity" and "Substance Use Disorders," "Neurobiological Mechanisms" (e.g., dopamine, brain plasticity), "Psychological Benefits" (e.g., stress management, mood enhancement), "Social Benefits" (e.g., social support, community engagement), "Intervention Studies and Effectiveness" (e.g., clinical trials, exercise programs), and "Comparative Approaches" (e.g., physical activity vs. traditional therapies). Only studies published from 1988 to 2024 and written in English were considered for review.

Inclusion and Exclusion Criteria

Studies included were randomized clinical trials, cohort studies, reviews, and meta-analyses that examined physical activity in the recovery of individuals with Substance Use Disorders. Studies were excluded if they were single case reports with limited practical use, or if they focused only on medication or talk therapy, or other treatments without including physical activity. Abstracts, conference presentations, and articles that were not available in full text were also excluded.

Data Extraction

The initial screening was done by reviewing titles and abstracts. Full-text articles were then reviewed based on the inclusion criteria. The most relevant articles were chosen based on the research areas, which included the brain mechanisms behind physical activity's effects on SUD recovery, its impact on abstinence and cravings, its influence on quality of life and mental health, the search for brain markers, and how different types of exercise affect various psychoactive substances. Any disagreements were resolved through discussion among the authors.

Barriers to Participation and Strategies to Enhance Adherence

Despite the proven benefits, many individuals with Substance Use Disorders find it hard to stick with physical activity, often because they lack proper facilities, social support, and motivation. Research suggests that obstacles can be physical, psychological, social, and logistical, with each type requiring specific strategies to encourage consistent participation. Recent studies show that personalized programs, education about the benefits of physical activity, and ongoing support can greatly improve participation and treatment results in SUDs. The variety of interventions studied also emphasizes the importance of offering flexible, patient-centered programs that fit different preferences and abilities.

Regarding psychological barriers, low motivation, poor self-esteem, and social anxiety are major hurdles to joining physical activity programs. Individuals with SUDs often show symptoms of depression and apathy, which negatively affect their drive to be physically active. Low self-esteem is also common and may cause individuals to avoid physical activity due to fear of not being able to maintain a regular routine or fear of being judged by others. Social anxiety is particularly high among individuals with SUDs, as many feel vulnerable in public or group settings, worrying about being compared to others. To overcome these barriers, mental support and building self-confidence are essential. Orientation sessions can help individuals set realistic goals and customize their programs, reducing performance anxiety and increasing belief in their abilities. Studies suggest that starting with low-intensity exercises in private settings or individual sessions can help lessen social anxiety and ease individuals into physical activity programs. Additionally, motivational techniques, such as tracking progress and positive feedback, increase self-confidence, encouraging individuals to continue with the program. To address psychological barriers like stigma or a lack of understanding about physical activity's benefits, incorporating group-based interventions or mindfulness activities like yoga has shown promise. These approaches not only build community but also help reduce resistance to treatment by creating a supportive environment.

Regarding physical barriers, many individuals with SUDs suffer from chronic physical conditions due to long-term substance use, which can limit their ability to do intense physical activities. Heart issues, breathing problems, and muscle pain are common in this group, making it hard to commit to activities requiring sustained effort. Physical withdrawal symptoms, such as fatigue and weakness, can also prevent regular participation in the first months of treatment. To address physical barriers, it is crucial to adjust physical activity programs to individuals' physical abilities. Studies suggest that low-impact exercises like walking, swimming, and stretching are particularly effective for improving physical fitness without putting extra strain on the body. Experts emphasize that involving physical therapists or specialized trainers can help individuals start safely, with a gradual and supervised physical activity program adapted to their physical abilities, thereby reducing the risk of dropping out due to physical difficulties.

For many individuals, limited access to sports facilities, lack of money, and time constraints are major logistical barriers. Financial problems are a particularly serious issue for those who have lost their jobs or face money struggles because of addiction. Additionally, a lack of transportation or being far from sports facilities can limit participation. Furthermore, for individuals who need to balance treatment with work and family duties, time is often a limiting factor that discourages them from engaging in physical activity. To reduce logistical barriers, home-based programs and physical activities that do not require expensive equipment or special spaces can be promoted. Studies show that exercises such as jogging, bodyweight exercises, and brisk walking are very accessible and effective, requiring minimal cost. Using monitoring apps and exercise video guides for home activities allows individuals to participate flexibly, removing the need to attend expensive or distant facilities. For those with limited time, shorter sessions spread throughout the day can be recommended, allowing them to gain benefits even with short periods of activity.

Lack of social support is also a critical barrier for many individuals with SUDs, who often live alone or have small social networks. This isolation reduces motivation to participate in physical activities and increases the risk of early dropout. Individuals lacking support may struggle to maintain a long-term commitment because they do not have a supportive environment to encourage them to pursue their recovery goals. Researchers suggest that small support groups within physical activity programs can offer individuals a safe space to share experiences and encourage each other, creating a supportive environment that boosts mutual commitment. The participation of family members in physical activities, when possible, can also offer additional support, improving participation and helping the individual in their fight against addiction. An often-overlooked barrier to participation is not knowing the benefits physical activity can bring to SUD treatment. Many individuals see physical activity as an optional or less important activity compared to other therapies, like medication or talk therapy, and do not fully understand its potential positive effects on preventing relapse. To increase awareness and motivation, research recommends adding physical activity education to treatment programs, offering informative sessions on specific benefits such as reducing cravings and positively impacting mood. Stories from patients and presentations of research findings can strengthen the perception of physical activity as an essential part of the recovery journey. Additionally, without a regular monitoring and feedback system, many individuals may easily lose motivation to participate in a physical activity program. The lack of feedback limits the feeling of progress, making it easier for individuals to leave the program. Studies highlight that regular monitoring and weekly feedback from healthcare providers significantly boost motivation and improve participation in physical activity programs. Follow-up sessions with trainers can help individuals stay motivated and adapt programs to their physical and psychological needs, reducing the risk of dropping out early.

Recommendations and Practical Implications

This review highlights the important role of physical activity in the treatment and recovery of individuals with Substance Use Disorders. Evidence shows that physical activity improves physical, mental, and behavioral outcomes. It is essential to turn these findings into practical strategies for clinical and community settings.

A key recommendation is that physical activity programs should be customized to each person's unique characteristics, such as the type of substance used, other health conditions, age, fitness level, and personal preferences. Personalized interventions improve participation and lead to better treatment results. For instance, activities like yoga or walking may be more suitable for individuals with physical limitations, while running or strength training might be better for those seeking greater physical challenges.

Combining physical activity with other treatment approaches, such as Cognitive Behavioral Therapy, motivational interviewing, or medication therapies, shows promising results. Such combinations address both the physical and mental aspects of recovery, creating a complete path for individuals. Furthermore, continued participation in physical activity programs can be supported through monitoring tools, like wearable devices or mobile apps, which provide real-time feedback and boost motivation.

In practical terms, physical activity should be regularly included in SUD treatment programs in both clinical and community settings. Accessibility can be improved by offering low-cost or free options, such as community walking groups or exercise plans for use at home. Facilities may also set aside resources for hiring exercise specialists or creating dedicated fitness spaces to support these efforts.

Improving participation in physical activity programs is crucial and can be achieved by addressing common barriers like lack of motivation, limited access, and insufficient social support. Starting with low-intensity activities and gradually increasing the intensity builds confidence and prevents overexertion. Group-based programs can foster a sense of community, reduce isolation, and improve accountability, while incentive systems, such as rewards or recognition for reaching goals, can further encourage participation. Healthcare providers play a vital role in promoting physical activity for SUD recovery. They should receive training on the benefits of physical activity and be prepared to address patient concerns, such as physical limitations or doubt about its effectiveness.

Additionally, adapting programs to different cultures and situations is essential to ensure that physical activity programs are relevant and accepted. Including traditional or region-specific activities can increase engagement and acceptance among diverse populations. Sustaining these interventions requires teamwork among healthcare systems, community organizations, and policymakers. Establishing long-term funding and prioritizing physical activity as a preventive and therapeutic tool in SUD treatment can make these programs a standard part of care. Ultimately, these efforts promise to improve the accessibility, participation, and effectiveness of physical activity programs, significantly enhancing outcomes for individuals recovering from SUDs.

Future Research Directions and the Importance of Longitudinal Clinical Studies

To further confirm the effectiveness of physical activity as an additional therapy for Substance Use Disorders, long-term clinical studies are crucial. These studies would monitor effects over time and fully understand how the amount of physical activity relates to patient outcomes. Such studies should explore not only the immediate effects of different types of physical activity (aerobic, HIIT, yoga, etc.) but also the lasting benefits over time, especially concerning preventing relapse and managing cravings.

Additionally, it would be valuable to test combining physical activity with other treatment methods, such as Cognitive Behavioral Therapy or medication, to assess how effective combined approaches are in managing SUDs. Specifically, using digital technologies for tracking progress and personalizing programs could offer new opportunities for improving treatments. Future research should also focus on how to adapt physical activity programs to different types of addiction (e.g., alcohol, drugs, stimulants) and the specific physical and mental needs of individuals, developing personalized treatment plans that maximize benefits and reduce relapse rates.

Future research should also aim to fill gaps in the current studies by looking into potential negative effects of physical activity in populations with co-occurring mental health conditions, such as bipolar disorder. Strict randomized controlled trials are necessary to reduce publication bias and provide a balanced understanding of both the benefits and risks of physical activity in diverse patient groups. Additionally, studies should explore personalized approaches that adjust physical activity routines to the unique needs of individuals with multiple mental health conditions. Incorporating new technologies, such as virtual reality and biomarker monitoring, could further enhance the safety and effectiveness of these interventions.

Study Limitations

While this review highlights the potential of physical activity as a therapy for Substance Use Disorders, it is important to acknowledge its limitations. Firstly, as a narrative review, it does not use a systematic method for collecting data, which could lead to bias in what studies are chosen. This limitation is made worse by including studies with different methods and mixed patient populations, making it hard to apply the findings generally. Secondly, most of the evidence comes from small-scale studies, which limits how broadly the results can be applied in real clinical situations. The variation in physical activity programs, including differences in type, intensity, and duration, further complicates drawing consistent conclusions. Additionally, the review mainly focuses on the benefits of physical activity, with limited exploration of potential negative effects or reasons why it might not be suitable for specific patient groups.

Conclusions

Physical activity is a promising and potentially effective additional therapy for managing Substance Use Disorders. It contributes to improved mental health and quality of life, reduced craving symptoms, and prevention of relapse. Evidence suggests that physical activity directly affects the brain, which is crucial for counteracting the long-term effects of substances, and for developing specific markers of its effectiveness. The ongoing development of research and the application of new technologies are essential to improve the effectiveness and long-term viability of these therapy programs. The goal is to promote more complete and lasting recovery for individuals with Substance Use Disorders.

The success of physical activity programs largely depends on overcoming barriers that limit participation, including physical, psychological, and logistical obstacles, while boosting patient motivation and making physical activity more accessible. This also means organizing social and health services for addiction care with this evidence in mind, thereby meeting the needs of health prevention and social integration. Exploring ways to adapt physical activity programs to different types of addiction and the specific physical and mental needs of individuals will pave the way for personalized plans that could maximize treatment benefits and significantly reduce relapse rates, contributing to a complete and sustainable therapy approach.

1. Introduction

Problems with substance use are a big challenge for people and countries around the world. These problems mean a person often keeps using a substance, even when it harms their body, mind, or life. This can lead to many health issues, social problems, and high healthcare costs.

Common ways to help, like medicine and talk therapy, work for many. But sometimes, these ways do not fully help a person get better for the long term. It is common for people to start using substances again. This shows there is a need for new and full ways to help people get well and stay well.

Recent studies show that physical activity (PA), like exercise, can be a helpful extra step in recovery. PA can help the brain and change behavior. For example, regular PA helps the brain grow and heal. It can also help fix the brain's reward system, which is often out of balance for people with substance use problems. Exercise can lessen bad feelings when stopping a substance, lower the urge to use, and make a person feel better. This is because it helps the brain’s chemicals, like dopamine, get back to normal. Also, PA can help with worry and sadness, which often happen with substance use problems. This means PA helps with other health issues that can make recovery harder. Studies have shown that exercise made for people with substance use problems can improve their health, mood, and overall well-being. Even studies on animals show that exercise can lower worry and prevent bad effects when stopping substances. This shows how PA can add to other treatments to help with all the complex parts of substance use problems.

This information will look at why physical activity helps with substance use problems. It will focus on how PA affects the brain, what good effects it has, and how it can be used in hospitals and communities. By looking at how PA affects a person's body, mind, and social life, this information hopes to show how PA can help people recover and live well for a long time.

This report is set up to first explain how PA helps the brain for people with substance use problems. Then, it will talk about different ways to use PA and if they work. Last, it will look at problems that stop people from doing PA and give ideas on how to add PA to treatment plans.

2. Results

Fifty studies were reviewed. The results were put into groups based on what they were about, like how PA helps the brain, how it affects the urge to use substances, its benefits for mental health, and how different types of PA work. These topics are discussed further, along with ways to help people stick with physical activity and ideas for future studies.

Physical activity helps people with substance use problems by changing how their brain works. It affects brain chemicals like dopamine and other important factors that help the brain grow and change. Exercise can make parts of the brain related to good feelings work better. It can also lower the stress hormone cortisol, which helps manage stress and worry, often a reason people start using substances again. Also, exercise can help balance brain activity over time, which supports staying away from substances. Scientists are also looking for brain signs that can show how a person might react to exercise. Brain scans can help show how PA changes the brain for people with substance use problems.

One of the most studied benefits of PA for substance use problems is its power to lower cravings and bad feelings when stopping a substance. Studies show that doing a moderate or strong amount of physical activity can greatly help people stop using substances, and it also helps with feelings like being annoyed, not being able to sleep, and feeling worried. Long-term studies show that PA helps people avoid going back to using substances, both early on and much later.

PA also leads to better mental health and a better life for people with substance use problems. Exercise, including walking or yoga, can lessen sadness and worry, improve mood, and make it less likely for a person to start using again. Group exercise can also help people think better and manage their feelings. These good effects happen because exercise raises levels of certain good chemicals in the body, which makes a person feel better. Exercises that focus on both body and mind, like Tai Chi, also help people manage their feelings, making them stronger inside.

The kind of physical activity and how hard it is can be very important in helping with substance use problems. Exercises like running and biking can reduce cravings for substances like cocaine by increasing good brain chemicals. Body-mind activities like yoga and Tai Chi help people manage their feelings and lessen worry, which is good for those with opioid and alcohol problems. Strong workouts might help the brain heal but need careful watching. It is important to find the right physical activity for each person based on their needs and how far along they are in their recovery journey.

3. Discussion

Physical activity helps people with substance use problems in many ways that go beyond just the body. These benefits can greatly help in the journey to recovery. They include becoming tougher, feeling more able to do things, better control over feelings, and less stress and worry. All of these are very important for handling urges and not starting to use substances again.

Being tough means a person can handle hard times and deal with stress in a good way. This is key for people trying to stop using substances. Studies show that PA can help people become tougher, making them better able to face the hard feelings that come with stopping substance use. This helps people deal with stress in healthier ways, instead of turning to substances. When people keep doing PA, this toughness gets stronger over time, which is very helpful for not starting to use again.

PA also helps people feel more sure of themselves. When a person does PA, they set goals and work towards them, which builds confidence. In recovery, people who feel more sure of themselves are more likely to believe they can stay away from substances and handle daily life without using. Seeing their bodies get stronger or last longer through PA can make them feel more in control of their recovery. Programs that slowly build up exercise goals help people feel more capable and motivated.

One clear benefit of PA is that it lowers worry and stress. These are big problems for people with substance use disorders and can make them start using again. PA helps lower stress hormones and releases good chemicals that make a person feel better. Body-mind activities like yoga have been shown to help lower worry for people with substance use problems. These activities mix movement with deep breathing and thinking, helping people relax deeply. They not only make a person feel better in the short run but also help them understand their feelings better, leading to better ways to handle stress.

PA also helps people manage their feelings better. This means they can respond to hard situations without turning to substances. Activities like jogging and walking can help people be less impulsive and control their feelings more. Mindfulness practices, like yoga, can also help people be more aware of their feelings and body, making them less likely to act without thinking and respond more calmly to daily problems. This is very helpful for people trying to stop alcohol or opioids, who often struggle with managing feelings and are more likely to relapse when stressed.

PA can also make people want to stay clean more because it makes them feel good and have more energy. People who add PA to their treatment often feel more eager to continue their recovery journey and live a healthy life. PA helps people be more active and also lessens feelings of not caring or not enjoying things, which are common with substance use problems. PA acts like a natural mood booster, helping with sad feelings and making it less likely to start using again when feeling down or alone.

Another good thing about PA is that it helps people sleep better. People with substance use problems often have trouble sleeping, which can make them more likely to start using again. PA, especially walking or running, can help with sleep, leading to better overall well-being and a lower chance of relapse.

How PA changes the brain, called neuroplasticity, is also very important. This is the brain’s ability to change and form new connections. Substance use often changes the brain’s reward system, making it harder to feel pleasure naturally and leading to strong cravings. PA helps fix these changes, especially by helping balance dopamine, a brain chemical linked to reward. Regular exercise helps the brain create healthy reward paths again, making people feel good in a natural way.

PA also affects a system in the body that helps control mood, pain, and stress. When people exercise, their bodies make natural chemicals that help calm stress and worry, which can explain why exercise helps lower cravings. This is very important for people in recovery, as high stress and worry often cause relapse. By helping this system, PA can make feelings more stable and reduce the bad feelings that come with stopping substance use.

PA also helps how the brain handles stress. Long-term substance use can make the body’s stress system work too much, leading to high levels of a stress hormone and making it harder to control feelings. PA can help calm this system. Also, PA can work well with other therapies, like talk therapy, by helping people think more clearly and manage their feelings. The brain's ability to change from PA is not just for a short time; it keeps changing with regular exercise, giving lasting benefits for people in recovery.

Recently, scientists are looking at how to use body signs and new tools to make recovery programs better. For example, looking at certain brain chemicals can help make PA plans more personal. New tools like special brain scans can watch how the brain changes during PA, showing how different people react. Also, new technologies like virtual reality are being used. These tools create fake real-world situations that can cause urges, letting people practice healthy responses while doing PA. Using these new tools in PA programs can help make them fit each person better, help more people stick with them, and offer ways to help many different people. Future studies should test these tools in real-world settings to see their long-term effects on preventing relapse and how they can be used with other treatments.

The kind of physical activity and how hard it is also matters for substance use problems. Different exercises can have specific effects based on the substance used, how far along a person is in recovery, and any other mental health issues. Exercises like running, walking fast, swimming, and biking are often studied for their help with stimulant problems like cocaine. These exercises release good brain chemicals that can reduce cravings and improve mood. Some studies suggest that these exercises can create a similar good feeling to drugs, helping to lower the desire to use. Aerobic exercises are also easy to do in many places and can be made easier or harder depending on the person. But very hard exercise might not be right for everyone, so it's important to choose wisely.

Mind-body activities like yoga and Tai Chi are becoming very helpful for opioid and alcohol problems. These exercises focus on movement, body awareness, and breathing, helping people manage their feelings and understand their bodies better. Recent studies show these activities can lower stress hormones and bring a sense of calm. This is especially good for people with substance use problems who also have worry or past trauma. These activities also help people control their actions, which is key to avoiding relapse. Since many people with substance use problems act on impulse when they have cravings, exercises like yoga can teach ways to manage these urges calmly. Studies show that people doing yoga programs for a few weeks had fewer cravings and slept better, which also helps prevent relapse.

Though less studied, very intense training, like HIIT, is gaining interest. It can improve physical strength and cause big brain changes, like increasing factors that help the brain heal areas damaged by long-term substance use. HIIT can also help people deal with stress and discomfort. However, its high intensity means it is not for everyone, especially those with heart problems or serious mental health issues. If watched closely, HIIT could be very helpful for people who are physically well and want a strong path to recovery.

Because different types of PA have different effects, the best way to help should be made just for that person. This means thinking about the type of substance used and the person's physical and mental state. For example, for people with alcohol or opioid problems who often feel worried or have trauma, body-mind activities might be very effective. For stimulant problems, where cravings are strong, regular aerobic exercise might be better at safely giving the brain the good feelings it seeks, lowering the desire to use.

A personal approach also means that activities can change as a person gets stronger and healthier in recovery. Studies suggest that starting with gentle body-mind activities and slowly moving to harder ones can make PA even more helpful for substance use problems.

Also, combining PA with other modern therapies, like special brain treatments or medicines, is becoming more popular. This can help the brain heal even more and support recovery.

Even with the good proof that PA helps with substance use recovery, there is a worry that studies mainly show good results. This might mean bad effects or limits of PA are not reported enough. This could make PA seem better than it is, especially for people with other mental health issues. For example, for people with bipolar disorder, strong exercise might cause their mood to change rapidly. Since substance use problems and bipolar disorder share some brain similarities, more study is needed to know if PA is safe and right for these people.

4. Limitations of the Current Literature

The studies on how physical activity helps people with substance use problems have taught us a lot, but they also have some limits. One main issue is that studies use different ways of doing things, like varying types of PA, how hard it is, and for how long. This makes it hard to compare studies directly and create standard treatment plans. Many studies also rely on people reporting their own PA habits, which can lead to mistakes or overstating the benefits.

Another limit is that studies often do not include many different kinds of people. Most studies focus on similar groups, often leaving out people with other mental health problems or serious physical limits, even though these are common for people with substance use problems. Also, there is not enough strong proof about the possible bad effects of PA, especially for people who are more at risk. For example, exercise might make mood swings worse for people with bipolar disorder, who have some brain similarities with people who have substance use problems. Also, using brain signs and new technologies in PA research for substance use problems is still very new. While some studies are looking at using brain scans and digital tools to track progress, these tools are not yet widely used or proven in real healthcare settings. This means we need more long-term studies that use these advanced tools to get clear and reliable information about the long-term good and bad effects of PA.

Lastly, there might be a bias where studies with good results are more likely to be published. This can make PA seem more effective than it truly is. To get a more balanced understanding of how PA helps with substance use problems, we need studies that include all results, even those that do not show a positive effect.

5. Materials and Methods

To gather information for this review, a search was done using major online research libraries. The search looked for keywords like "physical activity," "exercise," "substance use," "addiction," and "rehabilitation." This was to find studies from 1988 to 2024 that were written in English.

Studies were included if they were clear trials, long-term studies, reviews, or summaries that looked at physical activity in helping people with substance use problems. Studies were not included if they were about single cases, only focused on medicine or talk therapy without PA, or if their full text was not available. The most important articles were chosen based on how they fit the research areas, like how PA affects the brain, its effects on cravings and staying clean, its impact on mental health and quality of life, and how different types of exercise work with different substances.

6. Barriers to Participation and Strategies to Enhance Adherence

Even with all the good things physical activity can do, many people with substance use problems find it hard to stick with it. This is often because they lack proper places to exercise, social support, and motivation. Studies show that these barriers can be physical, mental, social, or about how things are set up. Each type needs its own plan to help people keep doing PA. Newer studies show that making PA programs personal, teaching people about the benefits of PA, and giving ongoing support can really help people stick with treatment and get better.

When it comes to mental barriers, low motivation, low self-worth, and fear of being around others are big hurdles to joining PA programs. People with substance use problems often feel sad or not caring, which makes them less likely to exercise. Low self-worth can also make them avoid PA because they worry they cannot do it or will be judged. Many people with substance use problems also feel very anxious around others, fearing comparisons. To help with these issues, mental support and building self-confidence are key. Planning sessions can help people set realistic goals and make their programs personal. This lowers worry about how they perform and makes them feel more sure of themselves. Studies show that starting with easy exercises in private or one-on-one can help lessen social anxiety. Tracking progress and giving positive feedback also build self-worth and encourage people to keep going. Group activities or yoga can also help create a supportive community and lessen the pushback to treatment.

For physical barriers, many people with substance use problems have long-term health issues from using substances for a long time. These can limit their ability to do hard physical activities. Heart problems, breathing issues, and muscle pain are common, making it hard to commit to activities that need a lot of effort. Also, bad feelings when stopping a substance, like being tired or weak, can stop people from exercising regularly in the first months of treatment. To help with physical barriers, PA programs must be made for each person's physical ability. Studies suggest that gentle exercises like walking, swimming, and stretching are very good for improving fitness without putting too much stress on the body. Having physical therapists or special trainers can help people start safely with an exercise plan that slowly builds up and is watched closely. This lowers the chance of people quitting because of physical problems.

For many, not being able to easily get to exercise places, not having enough money, and not having enough time are big practical problems. Money troubles are very serious for people who have lost their jobs or struggle financially because of substance use. Also, not having a ride or living far from exercise places can limit joining in. For people who have to balance treatment with work and family, time is often a big reason they do not do PA. To make these barriers smaller, programs that can be done at home and activities that do not need expensive gear or special places can be promoted. Studies show that simple exercises like jogging, bodyweight exercises, and fast walking are very easy to do and work well, needing little money. Using apps or exercise videos for home workouts means people can exercise when it works for them, avoiding expensive or far-away places. For those with little time, shorter exercise times spread throughout the day can still add up to good benefits.

Not having social support is also a major problem for many people with substance use problems, who often feel alone or have few friends. This loneliness lowers the desire to do physical activities and makes it more likely they will quit early. People without support may find it hard to keep going for a long time because they lack people to cheer them on in their recovery goals. Small support groups within PA programs can give people a safe place to share their experiences and help each other, building a supportive setting that makes everyone more committed. If possible, family members joining in PA can also give extra support, helping people stick with it and fight their substance problem.

A barrier often not thought about enough is not knowing how much PA can help with substance use treatment. Many people see PA as just an extra or less important activity compared to other treatments like medicine or talk therapy. They do not fully understand how much it can help prevent relapse. To teach people and make them want to do PA, studies suggest adding PA education to treatment programs. This means having sessions that teach about specific benefits like lowering cravings and improving mood. Hearing stories from other patients and seeing research findings can help people see PA as a key part of getting well.

Lastly, without regular checking and feedback, many people might easily lose their desire to do a PA program. Not getting feedback means people do not see their progress, making it easier to quit. Programs that watch progress, like using fitness apps or smartwatches, give quick feedback and encourage people to keep going. Regular checks and weekly feedback from health workers greatly boost motivation and help people stick with PA programs. Follow-up meetings with trainers can help people stay motivated and adjust programs to their physical and mental needs, lowering the risk of quitting too soon.

7. Recommendations and Practical Implications

This review shows that physical activity plays a big role in helping people with substance use problems recover. Proof shows that PA makes people better physically, mentally, and in their actions. Turning these findings into real plans for hospitals and communities is very important.

One main idea is that PA programs should be made to fit each person. This means thinking about the type of substance they used, any other health issues, their age, fitness level, and what they like. Personalized help makes people stick with the program more and helps them get better. For example, gentle activities like yoga or walking might be better for those with physical limits, while running or strength training might be good for those who want a bigger physical challenge.

Putting PA together with other treatments, like talk therapy, counseling, or medicines, gives good results. These mixed approaches deal with both the body and mind parts of recovery, helping people get better in a complete way. Also, keeping up with PA can be helped by using tools like smartwatches or phone apps that give real-time feedback and keep people motivated.

In real life, PA should be a regular part of substance use treatment programs in hospitals and communities. It can be made easier to access by offering low-cost or free options, such as community walking groups or exercise plans to do at home. Treatment places can also use money to hire exercise experts or create special fitness areas to help these efforts.

Helping people stick with PA programs is very important. This can be done by dealing with common problems like not being motivated, not having easy access, and not enough social support. Starting with easy activities and slowly making them harder builds confidence and stops people from overdoing it. Group programs can create a sense of community, make people feel less alone, and help them stay accountable. Rewards or praise for reaching goals can also encourage people to keep going. Health workers have a key role in promoting PA for substance use recovery. They should learn about the benefits of PA and be ready to help with people's worries, like physical limits or doubts about if it works.

Also, changing PA programs to fit different cultures and places is key to making sure they are liked and used. Adding traditional or local activities can make people more involved and help them accept the programs. Keeping these efforts going needs teamwork between health systems, community groups, and lawmakers. Setting up money for the long term and making PA a priority as a way to prevent and treat substance use problems can make these programs a normal part of care. All these efforts promise to make PA programs easier to get to, easier to stick with, and more effective, greatly helping people recovering from substance use problems.

8. Future Research Directions and the Importance of Longitudinal Clinical Studies

To make the case for physical activity as an extra treatment for substance use problems even stronger, long-term studies are needed. These studies should watch how PA affects people over a long time and help us truly understand how much exercise is needed for different results. Such studies should look at not just the immediate effects of different kinds of PA (like walking, intense training, or yoga) but also the lasting benefits, especially for stopping relapse and managing cravings.

Also, it would be useful to test PA combined with other treatments, like talk therapy or medicine, to see how well these mixed approaches work for substance use problems. Specifically, using digital tools to track progress and make programs personal could open up new ways to make treatments better. Future studies should also focus on how to change PA programs for different types of substance problems (like alcohol, drugs, or stimulants) and the specific physical and mental needs of people. This would help create personal treatment plans that get the best results and lower how often people start using again.

Future studies should also try to fill in what we do not know by looking into any possible bad effects of PA for people with other mental health problems, like bipolar disorder. Strong, fair studies are needed to make sure we get a balanced view of both the good and bad sides of PA for different groups of people. Also, studies should look at personal plans that change PA routines to fit the special needs of people with more than one mental health issue. Using new technologies, like virtual reality and tracking body signs, could make these treatments even safer and more effective.

9. Study Limitations

While this review shows how physical activity can help with substance use problems, it is important to know its limits. First, because this review tells a story rather than uses a strict method to collect information, it might have only picked certain studies, which could lead to a biased view. This is made harder because the studies included used different methods and involved different kinds of people, making it tough to say that the findings apply to everyone. Second, most of the proof comes from small studies, which limits how much we can apply it to larger groups of people. The many differences in PA programs, like the type, how hard they are, and how long they last, also make it hard to reach clear conclusions. Also, this review mostly focuses on the good things about PA, with little talk about possible bad effects or if it is not suitable for certain groups of people. For example, exercise might make mood swings worse for people with bipolar disorder, who have some brain similarities with people who have substance use problems. Also, exploring brain signs and new technologies in PA research for substance use problems is still in its early stages. While new studies have started to look at using brain scans and digital health tools to track treatment progress, these tools are not yet widely used or proven in real healthcare settings. This gap shows the need for more long-term studies that use advanced tools to give clear and reliable facts about the long-term benefits and risks of PA programs.

Lastly, there might be a bias where studies with good results are more likely to be published. This can make PA seem more effective than it truly is. To get a more balanced understanding of how PA helps with substance use problems, we need complete reviews that include studies with all results, even those that do not show a positive effect.

10. Conclusions

Physical activity is a promising and possibly effective extra treatment for substance use problems. It helps improve mental health and life quality, lessens cravings, and prevents people from starting to use substances again. Proof suggests that PA directly affects the brain, which is key in fighting the long-term effects of substances and finding special signs of how well it works. The ongoing growth of research and the use of new technologies are important to make these treatment programs better and last longer. The goal is to help people with substance use problems recover in a fuller and more lasting way.

For PA programs to work well, they need to overcome things that stop people from sticking with them. These include physical, mental, and practical problems. Boosting how motivated people are and making PA easy to get to are key. This also means that health and social services for addiction care should be set up with this information in mind, meeting needs for staying healthy and being part of the community.

Finding ways to change PA programs for different types of substance problems and the specific physical and mental needs of people will lead to personal plans. These plans could greatly increase the good effects of treatment and lower how often people start using again, leading to a complete and lasting way to help.