Mind-Body Approaches to Prevention and Intervention for Alcohol and Other Drug Use/Abuse in Young Adults

Alcohol and other drug (AOD) misuse is highly prevalent among young adults and creates myriad long-term problematic social, economic, and health consequences. Current treatments aimed at preventing or alleviating AOD misuse have demonstrated fairly inconsistent and weak effectiveness and, thus, are far from a complete solution. In this review, we describe the current state of AOD interventions for young adults and present an alternative emotion regulation framework for understanding AOD use/misuse. We then describe implications of this framework for interventions to promote healthier emotion regulation to successfully reduce AOD use/misuse. In particular, we assert that mind–body approaches, such as meditation, distress tolerance, and yoga, may promote emotion regulation skills that allow young adults to manage their stressful experiences and distressing emotions without AOD use. We review the available literature on mind–body interventions targeting AOD use/misuse in young adults and offer suggestions for future intervention development and research.


Problematic Alcohol and Other Substance Use in Young Adults
Both alcohol and other drug (AOD) use are highly prevalent in the US and are associated with many adverse consequences, many of which manifest in young adulthood. Excessive alcohol use is the fourth leading cause of death in the United States [1]. Results from the most recent National Survey on Drug Use and Health (NSDUH) [2] indicate that 18-25-year-old respondents reported the highest alcohol use rates (over 58%) as well as the highest rates of heavy episodic or "binge" drinking of any age group. Over one-third of all 18-25-year-old participants indicated that they had consumed 4-5 drinks or more in a single occasion during the previous 30 days. The prevalence rate of heavy episodic drinking for this age group is at 34%, which is just below the highest historical rates ever recorded by this survey. Problematic alcohol use in young adults is associated with myriad negative consequences, including fatal and nonfatal injuries [3], physical violence against others [4], sexual assault victimization and perpetration (e.g., [5][6][7]), being bullied [8], increased risky sexual behavior (e.g., [9,10]), mental health problems (especially elevated depression [11,12]), and decreased odds of post-graduation employment-post-graduate employment is typically a goal of undergraduate college students [13].
Drug-related deaths continue to be on the rise in the US [14] with age-adjusted overdose death rates increasing 15.6% from 2014 to 2015 and 21.5% from 2015 to 2016 [14]. These increases were observed across all age groups and across multiple substances but were particularly evident among young adults in their mid-twenties [14]. Results from the 2015 Monitoring the Future national survey on drug use [15] suggest that "by their late 20s, nearly two-thirds (63%) of today's young adults have tried an illicit drug, and about four in ten (37%) have tried some illicit drug other than marijuana, usually in addition to marijuana" [15] (p. 38). College students have the highest prevalence of any age group of illicit drug use (41%)-higher than their non-collegiate 19-28-year-old peers or high school-aged adolescents. Their prevalence rate for illicit drug use other than marijuana use is also the highest, tied at~20% for both college students and their 19-28-year-old non-collegiate peers. Rates of marijuana use from 2014 to 2015 increased to 34% among the general young adult population and to 28% among college students-the highest rates recorded in 25 years.
The National Comorbidity Survey (NCS) underscores that AOD use initiated in the period of young adulthood is not just experimental and recreational but rather may have lasting effects on consumption trajectories: For the majority of adults diagnosed with a substance use disorder, onset occurred during young adulthood [16]. Effective interventions for young adults are crucial in preventing the escalation of AOD misuse into disordered behavior, and there is growing consensus that not all intervention approaches are equally effective across the heterogeneous population of substance-using young adults. The development of biopsychosocial models customized to individual patient's needs and characteristics are needed for the prevention of AOD misuse. For example, recent advances in substance use research suggest that chronic and severe substance-using populations may differ in important ways (e.g., specific types of cognitive impairments), which is informative in tailoring treatment approaches (e.g., chronic and severe marijuana, alcohol, and cocaine users [17]).

Current Approaches to Reducing Substance Use in Young Adults
Research suggests that there are possibly at least four different motives that may drive heavy (and problematic) AOD use: coping, enhancement, social, and conformity (peer pressure) [18]. Although using AOD to cope (i.e., coping motives, which relate to the relief of anxiety or depression) has been identified as important, current widely-used AOD misuse intervention programs (for example, Brief Alcohol Screening and Intervention for College Students, BASICS, and Marijuana Abuse Prevention Program, MAPP [19]) are typically based on the idea that students' AOD Misuse is influenced by the conditions of the college environment where students feel pressure to fit in and conform. These programs often view the college environment as one where AOD misuse is prevalent and perceived as normative.
Accordingly, these collegiate intervention programs aim to enhance individuals' self-efficacy and motivation to "act responsibly" with respect to AOD use [20]. Treating problematic substance use as a misinformed choice, these programs employ brief motivational interventions (BMIs) to provide personalized feedback with regard to the consequences of use, normative (mis)perceptions about other students' use, and expectancies regarding the effects of substance use. Many collegiate substance use prevention programs rely on intervention curricula informed by BMI approaches, some employing web-based adaptations, which have demonstrated modest efficacy with respect to short-term reductions in alcohol use [20], but minimal long-term impact [21]. Evidence regarding the impact of BMIs on drug use, especially among those who are not identified as also having problematic alcohol use, is also mixed [22] with several controlled studies [23,24], suggesting limited or no impact. These inconsistent and short-term effects may be the result of an intervention approach that only partially addresses a subset of the underlying factors leading to young adults' AOD misuse. In particular, we assert that promoting more effective coping skills to regulate negative emotions might be a useful intervention approach for reducing use and misuse of AOD.

An Emotion Regulation Perspective on Young Adults' AOD Use/Abuse
Emotion regulation (ER) refers to "extrinsic and intrinsic processes responsible for monitoring, evaluating, and modifying emotional reactions, especially their intensive and temporal features, to accomplish one's goals" [25] (p. 27). During young adulthood, critical changes in ER occur, particularly age-related shifts in strategies used to manage distress (e.g., emotion suppression, inhibitory control, and cognitive reappraisal [26,27]). The effortful or planful and strategic management of distress is quite salient in young adulthood, a developmental period marked by an immature emotion regulatory system with heightened reward sensitivity and less inhibition of impulsive behavior [28][29][30][31][32]. Substantial evidence suggests that deficits in ER are strongly related to patterns of AOD use in young adults [33][34][35][36].
In particular, deficits in the self-regulation of discomfort and distress, called distress tolerance, predict use-specifically, motivation and urgency for use, escalations in consumption, and the development of dependence that may indicate substance use disorders (SUDs) [33,37]. Copious research has linked substance use specifically to difficulties in ER, describing substance use as a strategy individuals use to escape, avoid, or regulate emotional discomfort [38]. Young adults who lack more adaptive ways to regulate emotions may turn to substances as a way to minimize or numb negative emotions. Substance use prevention and treatment efforts then are best able to address the relationships between substance use and mood by considering how emotional experiences underlie or exacerbate maladaptive coping strategies. As noted by Dingle and colleagues [39], "even following treatment, emotional distress is the number one trigger for relapse into substance misuse" (p. 187). Thus, learning ER skills, particularly the management of distress, holds significant promise in preventing the escalation of AOD misuse to SUDs in young adulthood.
Impaired ER is associated with substance use initiation and on-going use despite negative consequences, setting the stage for substance use disorders [30,40]. Moreover, AOD misuse may be a coping strategy for young adults unable to otherwise regulate discomfort and distressing emotions [41,42]. In turn, substance use may impair the development of executive functions [17]. In sum, impaired and still-developing ER skills in young adulthood comprise a complex constellation of initiating and exacerbating factors occurring in a sensitive developmental period [43,44].

Mind-Body Interventions for Emotion Regulation in the Context of Substance Use/Abuse
Importantly, social norms and BMI interventions do not address ER difficulties, a primary driver of AOD misuse that can persist beyond the college years and far into adulthood. Given the incomplete and variable effectiveness of these approaches for reducing young adults' substance misuse [21,45], there is a clear need for alternative intervention approaches. Research on the strong associations between ER and AOD use in young adults [33,34] suggests that attending to their individual resources and coping skills may be critical for effective interventions to prevent escalating substance misuse. Indeed, we know from an extensive literature that chronic stress creates vulnerability to addiction (e.g., [46]) and impacts alcohol use and other related behaviors (e.g., [47]). Accordingly, when young adults learn ER skills-particularly when they learn how to effectively manage discomfort and distress-these skills hold significant promise in stemming the escalating AOD use towards SUDs.

Mind-Body Approaches to Bolstering ER Skills to Prevent AOD Use/Misuse
Individuals regulate their emotional distress and discomfort associated with stressors in a myriad of adaptive or maladaptive ways, often including AOD use. Emotion regulation depends on an individual's unique mental representations of everyday and stressful events through which they interpret and navigate daily life [48]. Within this framework, self-evaluation is critically important in order to respond adaptively to distressing emotions. For example, the ability to monitor one's efforts to regulate or manage discomfort or distress and evaluate the effectiveness of these attempts are undergirded by a mindful ongoing awareness of one's physical and emotional state. Further, possessing coping skills that allow individuals to reappraise discomfort or distress as manageable, as well as having adequate internal resources such as self-efficacy and control, also allow individuals to more adaptively regulate their emotions [49,50].
Thus, interventions that target ER by bolstering self-reflection/evaluation, imparting ER skills, and increasing internal resources present opportunities to build resilience [50]. Mind-body interventions for AOD misuse, which aim to prevent escalations by acknowledging the influence of physical and mental health within the social context of young adult life, do just this and are a natural adjunctive approach to those focused on social influence to create a more comprehensive strategy to AOD intervention. To date, mind-body approaches have not been extensively applied to AOD use and misuse, and very little of this research has been conducted with young adults. In the section below, we review the literature on mind-body interventions focused on emotion regulation in young adults, with a focus on those targeting AOD use. In particular, we review mindfulness approaches to increasing ER in young adulthood focusing on distress tolerance interventions and yoga-based interventions.

Distress Tolerance Interventions to Improve ER and Reduce AOD Use/Misuse
Studies have convincingly demonstrated the effectiveness of ER interventions to impact dysregulated behavior, noting these efforts are promising because they focus on individual's struggles to regulate themselves when experiencing intense negative emotions [51][52][53]. Specifically, distress tolerance (DT) represents a promising ER mechanism for preventing AOD use [34,50,54,55]. DT interventions focus on equipping individuals with ER skills that encourage deescalating an intense or impulsive emotional response to distress to a calmer, more mindful response. This response is more likely to include adaptive coping strategies and less likely to include impulsive or harmful responses to distress, including substance use.
Mindfulness and meditation activities common in these efforts promote emotional clarity by training individuals to attend to present experiences non-judgmentally [56]. With practice, individuals who can mindfully attend to their emotions experience fewer moments of crisis and build a sense of competence in regulating their distress-thereby becoming more self-efficacious in their resilience [57]. Similar to most mindfulness-based interventions, DT interventions are often didactic social small group interventions that present activities and conversation topics to promote ER [58]. Participants in these interventions are taught self-reflection, non-judgmental awareness of their experiences, and adaptive coping strategies-often through meditation and similar reflective practices such as guided or self-visualization-in an effort to promote self-management and health and wellbeing.
Development of mindfulness-based approaches to AOD use in young adults is in a very early stage but results so far are promising, suggesting that increasing mindfulness may reduce negative affect and subsequent urges to engage in AOD use [18,[59][60][61][62][63]. For example, a two-session mindfulness and motivational interviewing intervention demonstrated reduced marijuana use over three months in young women [64].
Building on these more general mindfulness approaches to young adult AOD use, DT has demonstrated significant associations with lower levels of substance use [65][66][67][68][69][70][71]. This evidence suggests DT is a significant correlate and moderator of AOD use. However, there is a noteworthy gap in the literature specific to young adults. To date, we are aware of only one randomized controlled trial of a DT intervention to reduce substance use in any age group: In a sample of 49 individuals (mean age 40 years), Stein and colleagues [72] reported positive effects from their DT training series of seven 50-min sessions. Given the shifts in ER during this stage of development and the high rates of AOD use in young adulthood leading to SUDs, more work in this area is sorely needed.

Yoga to Improve ER and Reduce AOD Use/Misuse
As noted above, ER involves self-awareness, cognitive reframing, and mindfulness, all of which increase one's capacity to control, override, or accept spontaneous negative emotional responses [50]. Yoga has been suggested to be an exceptional path towards skillful ER [73] and thus may provide a highly effective route towards alleviating AOD use/misuse. Many of the beneficial effects of yoga on physical, mental, and spiritual well-being can be attributed to its fostering a greater capacity for ER.
Classical yoga was originally designed to create mind-body harmony and aid in the ultimate goal of "enlightenment" [74]. In the past century, yoga has evolved considerably, with much greater emphasis placed on the physical aspects of yoga postures (asanas) and practice. Hatha yoga, the modality most often practiced in the United States, involves the practice of yoga postures together with breathing techniques and concentration/meditation [73]. Many aspects of yoga practice help to develop and support ER [75], including meditative movement, conscious breathing, body and emotion awareness, open curiosity, attention allocation, self-compassion, and acceptance [73,76]. Through these aspects of yoga, practitioners can strengthen their capacity for emotional stability and equanimity, an even-minded mental state or dispositional tendency toward all experience regardless of its affective valence or source. Through continued practice, yoga can help individuals cultivate more adaptive and fewer maladaptive cognitions, emotions, and behaviors. In combination, these different aspects of yoga make it a highly potent intervention for improving self-regulation capacity. With more yoga practice, practitioners develop greater tendencies for adaptive ER, both on and off the yoga mat.
Yoga interventions for ER have demonstrated feasibility in a variety of settings, including a small number of studies conducted with young adults [76][77][78][79]. Based on these and other studies, Khanna and Greeson [80] noted that "the skills, insights, and self-awareness learned through yoga and mindfulness practice can target multiple psychological, neural, physiological, and behavioral processes implicated in addiction and relapse. A small but growing number of well-designed clinical trials and experimental laboratory studies on smoking, alcohol dependence, and illicit substance use support the clinical effectiveness and hypothesized mechanisms of action underlying mindfulness-based interventions for treating addiction" (p. 244). For example, a randomized controlled trial found that alcohol-dependent participants in an eight-week yoga intervention had greater declines in dependence severity compared to participants in the physical training exercise control condition [81]. Among clients in an outpatient methadone program, yoga interventions have been shown to be as effective as traditional group psychotherapy for reducing substance use [82]; similarly, a yoga intervention in a military population was associated with significantly reduced rates of alcohol and substance use [83].
To date, however, no research has examined the utility of a yoga intervention to reduce AOD use/misuse in young adults, perhaps because people who engage in substance misuse are typically excluded from studies of yoga interventions [84]. Results of a recent national survey indicate that nearly 20% of young adults in the US aged 18-29 currently practice yoga [85]; as yoga continues to grow in popularity in the United States, the study of its effects on ER and AOD has the potential to make an important and timely contribution to developing more effective substance use interventions for young adults.

Issues for Future Development of Mind-Body Approaches to Reducing AOD Use in Young Adults
Given the broad and burgeoning interest in meditation and yoga interventions for a host of mental and physical disorders [86,87], it is somewhat surprising that so little research has investigated their potential efficacy for treating AOD use/misuse in the high-risk group of young adults. Young adults are quite interested in meditation and yoga. For example, the number of young adults who had practiced yoga in the past year had increased to nearly 30% in the most recent NHIS survey [88]. Given this interest, these approaches may have broad appeal and acceptability. Clearly, this is an area warranting substantial research attention, given the promising findings regarding their efficacy for many other conditions [89] and the direct effects they have demonstrated on ER skills.
Further, research is needed on how these complementary approaches might best be integrated into existing interventions for young adults-including on college campuses where over 70% of young adults pass through [90]-given the wide reach of existing interventions. While the efficacy of existing programs may be limited, they have widespread institutional acceptance in the US and have been easy (and cost-effective) to implement. Indeed, some of these traditional interventions have been adapted so that they can be accessed online through personal electronic devices (e.g., Alcohol e-CHeckUpToGo (e-CHUG) [91]). DT-and yoga-based approaches currently require face-to-face interaction and skilled trainers need to be available to work with live groups of students. However, new technologies are being developed to deliver such interventions remotely, both synchronously and asynchronously [92]. Can young adults be cost-effectively treated with such interventions, given the limited budgets of many institutions of higher education and our health care system? Is it possible to "mass produce" yoga and DT interventions in the same way that existing BMI interventions have been developed nationwide in the US? These implementation issues require further exploration in future research.
Finally, any potential implementation of yoga/DT interventions would require assessment of AOD outcomes as well as of theoretically informed measures reflecting the potential processes that underlie AOD use. Thus, researchers should measure levels of DT and ER as well as other variables that potentially may impact substance use and substance use motives. This assessment would be especially important if the yoga/ER interventions were developed as an adjunct to existing BMI or social norm programming. Enhancement of programming requires a clear understanding of the mechanisms of action and such an understanding requires careful measurement not only of outcomes but of intervening processes. With this comprehensive measurement and the resulting refinement of theory, we can develop improved programming to more effectively address the problem of AOD use/misuse in young adults.