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Published in final edited form as: Policy Insights Behav Brain Sci. 2022 Sep 10;9(2):156–163. doi: 10.1177/23727322221113037

Heart Rate Variability Biofeedback for Substance Use Disorder: Health Policy Implications

Sarah T Wieman 1, David Eddie 2,3
PMCID: PMC12890217  NIHMSID: NIHMS2144653  PMID: 41675429

Abstract

Substance use disorder (SUD) exacts massive individual and public health burdens, in part because of its relapsing nature. First-line SUD treatments aim to strengthen affective and cognitive control to help individuals override impulses to use alcohol and other drugs, yet automatic physiological processes compromised by SUD interact with affective states and the environment, compromising effortful cognitive control and undermining attempts to avoid substance use. While existing first-line SUD treatments may indirectly help offset these vulnerabilities, none target them. Heart rate variability biofeedback (HRVB) involves rhythmic breathing that directly targets these deficits, complementing first-line SUD treatments. HRVB has evolved from a clinic-based treatment to an ambulatory intervention utilizing wearable biosensors and smartphone applications with capacity for just-in-time support of affective and behavioral self-regulation. There is evidence supporting the efficacy of HRVB for SUD, but more research is needed to fully assess HRVB’s potential to support SUD recovery and inform policy.

Keywords: heart rate variability biofeedback, 6 breaths per minute breathing, substance use disorder recovery, autonomic nervous system, affect and behavior regulation

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#HeartRateVariabilityBiofeedback shows promise as a complement to first-line #SubstanceUseDisorder treatments. This paper discusses the next research steps, and policy changes needed to increase access to this promising treatment tool.

Introduction

In 2020, 20.7 million people in the United States met criteria for substance use disorder (SUD; SAMHSA, 2021), exacting a massive individual and public health burden. While effective first-line treatments exist for SUD that ultimately help the majority of people recover in the long term, relapse rates are high (e.g., Maehira et al., 2013), compounding this health burden. This signals a critical need for novel interventions that can augment first-line treatments and prevent relapse.

For individuals in early recovery from SUD, high affective intensity and instability, low distress tolerance, and impaired cognitive and behavioral control are major contributors to relapse (e.g., Gorka et al., 2012; Simons et al., 2009; Thorberg & Lyvers, 2006). In a vicious, cycle, for many individuals, acute and chronic stress give rise to craving, and craving, in turn, produces stress (Fox et al., 2007).

While many aspects of affective dysregulation in SUD arise from neurological dysregulation at the level of the brain (Koob & Volkow, 2010), the way affective states are experienced and regulated also involves dynamic, bidirectional brain-body communication through autonomic pathways linking the brain and cardiovascular system (e.g., Critchley, 2005; Eddie et al., 2022). As such, adjunctive interventions that target affective vulnerabilities at the level of the body and brain may offer important treatment benefits not currently conferred by existing first-line SUD treatments.

Here we highlight how dysregulation of the brain and body may contribute to development and maintenance of SUD. We then introduce a novel, breathing-based intervention, heart rate variability biofeedback (HRVB) that may help address these vulnerabilities. We then discuss how new technologies address problems of accessibility and scalability associated with first-generation HRVB, noting future directions for research, and making policy recommendations.

Substance Use Disorder Arises out of Affective and Behavioral Regulatory Impairment at the Level of the Body as well as the Brain

The central autonomic network (CAN) is a constellation of interacting neural structures that facilitate the integrated brain–body communication that underlies affective and behavioral control (Benarroch, 1997; Card & Sved, 2011; Jellinger, 1998). The CAN supports self-regulation through several physiological systems, adjusting physiological arousal based on situational demands (Friedman & Thayer, 1998).

The effects of CAN on the cardiovascular system are especially pronounced. Neural communication from the CAN, communicated via the autonomic nervous system, converges on the heart’s central pacemaker, causing the heart rate to increase or decrease dynamically in response to internal and external stimuli and needs (Bibevski & Dunlap, 2011; Katz, 2010). Heart rate variability (HRV), or the subtle changes in the time intervals between heartbeats, is a physiological measure of this neurocardiac communication and reflects CAN affective regulatory capacity (e.g., Benarroch, 1997; Thayer & Brosschot, 2005; Vaschillo et al., 2011). Note that it is the variability of heart rate, not its average that matters here, and that HRV reflects flexible, responsive adaptation to environmental demand.

High resting HRV is typically associated with psychological and behavioral health, while low HRV commonly co-occurs with psychiatric disorders (Buckman et al., 2018; Lehrer & Eddie, 2013), such as SUD (Buckman et al., 2015), major depressive disorder (Koch et al., 2019), PTSD (Schneider & Schwerdtfeger, 2020), and anxiety disorders (Chalmers et al., 2014).

In the case of SUD, lower resting HRV is also associated with greater substance use (Henry et al., 2012; Ralevski et al., 2019), greater SUD symptom severity (D’Souza et al., 2019), higher levels of craving (Quintana et al., 2013), and higher probability of relapse (Garland et al., 2012). The relationships between HRV and substance use may reflect CAN dysregulation leading to a loss of capacity to respond flexibly and effectively to internal and external perturbation (Eddie et al., 2022), thereby making a person more likely to rely on substance use to cope.

These systems are malleable, however, and with SUD recovery, this dysregulation may in-part or fully resolve. For instance, HRV has been shown to increase among women receiving cognitive behavioral therapy for alcohol use disorder (Buckman et al., 2019). These significant improvements remained after controlling for in-treatment drinking, suggesting that CAN regulatory improvements were a response to treatment and not simply a function of reduced alcohol consumption. HRV in individuals with alcohol use disorder and nicotine dependence has also been shown to spontaneously improve with abstinence from these substances (e.g., Harte & Meston, 2014; Ralevski et al., 2019).

And yet, high relapse rates associated with SUD suggest that CAN dysregulation remains a vulnerability for many individuals in early recovery. While treatments like cognitive behavioral therapy likely help, no first- or second-line SUD treatments directly target this dysregulation. Adjunctive treatment approaches that directly target autonomic dysregulation would likely support psychological and pharmacological SUD treatments by covering this critical gap.

Heart Rate Variability Biofeedback Reduces Negative Affect in a Range of Psychiatric Conditions

HRVB is an intervention that uses rhythmic breathing to stimulate two reflexes that influence heart rhythm—the respiratory sinus arrhythmia and the baroreflex—to support affective and behavioral self-regulation and ameliorate negative affect.

The respiratory sinus arrhythmia arises from the entrainment of the pulmonary and cardiovascular systems, such that heart rate dynamically responds to respiration, with heart rate generally increasing during inhalation and decreasing during exhalation. The baroreflex, which is also influenced by respiration, supports dynamic arterial blood pressure regulation via receptors on artery walls that stretch in response to moment-to-moment changes in blood pressure, feeding this information up to the CAN. In turn, the CAN adjusts heart rate and blood pressure based on physiological states and situational demands. In essence, HRVB involves teaching patients, with the help of biofeedback, to breathe at the frequency that optimally stimulates these systems.

This optimal breathing frequency varies from person to person, but on average it is 5.5 breaths per minute (Vaschillo et al., 2006). Because 6 breaths per minute breathing is easy to pace using a clock (i.e., 1 breath cycle per 10 s) and close to the average optimal frequency, many clinicians teach patients 6 breath per minute breathing (i.e., 4 s inhalation, 6 s exhalation), especially when they do not have training in HRVB or access to the equipment to determine a patient’s exact resonance frequency.1

HRVB measurably ameliorates negative affect in a range of psychiatric conditions (e.g., Goessl et al., 2017; Lehrer, 2017, 2018; Lehrer et al., 2020; Pizzoli et al., 2021) and improves cardio-respiratory outcomes in several physiological conditions (Lehrer et al., 2004; Yu et al., 2018). A recent HRVB meta-analysis found medium to large effect size reductions for anxiety, depression, and anger, with smaller effect size improvements in PTSD symptoms and sleep quality (Lehrer et al., 2020). Other recent HRVB meta-analyses have found a medium effect on depression (Pizzoli et al., 2021) and a large effect on self-reported stress and anxiety (Goessl et al., 2017). Given the growing evidence base for HRVB’s capacity to reduce negative affect in a range of clinical presentations, researchers have begun exploring its potential to support first-line SUD treatments (for reviews see, Eddie et al., 2015; Leyro et al., 2019).

Heart Rate Variability Biofeedback Reduces Craving and Other Forms of Negative Affect in Individuals with Substance Use Disorder

To date, seven studies have examined the potential of HRVB to support SUD recovery, most with an emphasis on mitigating SUD relapse risk by reducing craving (Alayan et al., 2019; Eddie et al., 2014, 2018; Nyx, 2021; Penzlin et al., 2015; Yen et al., 2022; Zucker et al., 2009). HRVB has been shown to reduce craving when added to inpatient care (Eddie et al., 2014; Penzlin et al., 2015), recovery housing (Eddie et al., 2018), and partial hospitalization and outpatient programs (Nyx, 2021; Yen et al., 2022; Zucker et al., 2009). Closely related 6 breaths per minute breathing has also been shown to buffer craving increases in outpatient samples (Price et al., 2022).

Preliminary evidence also suggests that HRVB may produce benefits in terms of reducing SUD severity and rates of substance use at post-treatment and 1-month follow-up (Yen et al., 2022), as well as symptoms of depression and anxiety among inpatient SUD treatment populations (e.g., Penzlin et al., 2015; Zucker et al., 2009).

Given craving, anxiety, and depressive symptoms are all known risk factors for SUD relapse (e.g., Fatseas et al., 2015; Witkiewitz & Wu, 2010), HRVB’s capacity to ameliorate this negative affect would likely translate into better SUD recovery outcomes, however, more research is needed to determine if this is, in fact, the case.

Heart Rate Variability Biofeedback is Now Accessible and Scalable, Using Current Devices

HRVB has numerous strengths and benefits making it an attractive adjunct to first-line SUD treatments (Eddie et al., 2015). As an intervention, it has no adverse side effects or contra-indications. However, first-generation HRVB had major limitations with regards to its accessibility and scalability.

As first devised, HRVB was delivered over the course of 10 clinic sessions using expensive laboratory equipment (Lehrer et al., 2000). More recent studies have shown that fewer sessions (i.e., 3–6 sessions) show benefits in terms of craving and affect dysregulation in individuals with SUD (e.g., Eddie et al., 2014; Nyx, 2021; Penzlin et al., 2015); however, even brief courses on HRVB present barriers to uptake including costly equipment and the need to find a clinician trained to deliver HRVB (of which there were few).

Additionally, first-generation HRVB interventions focused on positive behavioral effects (e.g., decreases in craving and depressive symptoms) that accrue over weeks or months of regular daily breathing practice (e.g., Alayan et al., 2019; Eddie et al., 2018; Zucker et al., 2009). Regular daily practice, though beneficial, is likely to only partially mitigate the intense momentary bouts of emotion dysregulation that are critical triggers for substance use and relapse in those in early SUD recovery. There was a clear need for strategies for managing intense negative affect in-the-moment. While chronic behavioral changes are valuable, the multiple clinical sessions and daily practice were labor and time intensive, further reducing the likelihood of large-scale uptake of HRVB.

Recent technological advances have given rise to low-cost, wearable devices for convenient daily HRVB practice, while also supporting in-the-moment, as needed, HRVB practice (e.g., Chung et al., 2021). These devices are widely available, integrate with end-users’ smartphones, and do not require a provider to administer the intervention.

Further, several smartphone applications are available that use the smartphone’s camera as a sensor to support HRVB. Individuals place their index finger on the camera lens and are prompted by an application to breathe at resonance frequency. Individuals using such HRVB smartphone applications after a laboratory stressor task have shown significantly reduced levels of a stress biomarker (salivary alpha-amylase) compared to controls (Holmes et al., 2020; Hunter et al., 2019).

Perhaps what’s most exciting about second-generation HRVB wearable devices is that they can function as just-in-time interventions, in which patient physiology is passively monitored, and when autonomic hyperarousal is detected, a 2-min burst of HRVB practice is prompted, which may help the wearer down-regulate autonomic arousal (e.g., Chung et al., 2021). Therefore, unlike smartphone applications in which individuals must actively monitor their own urges/affective states and then choose to engage in HRVB exercises, wearable devices can passively monitor physiological changes and alert the individual to when it may be beneficial to engage in HRVB.

Preliminary evidence suggests that this kind of in-the-moment practice of HRVB or 6 breaths per minute breathing may have clinical benefits, with recent work showing that a brief exposure to these interventions in anticipation of psychosocial stress, or during induced stress, reduces physiological arousal and state anxiety, and improves cognitive performance (Bates et al., 2019; Prinsloo et al., 2011; Wells et al., 2012).

Taken together, second-generation HRVB devices and smartphone applications have major potential to increase the efficacy, accessibility, and scalability of HRVB.

Research is Needed to Fully Understand the Potential of Heart Rate Variability Biofeedback as an Substance Use Disorder Intervention

HRVB delivered in the context of SUD treatment as usual may decrease craving and other forms of negative affect (e.g., Eddie et al., 2018; Nyx, 2021; Penzlin et al., 2015). HRVB may even decrease substance use and SUD severity (Penzlin et al., 2017; Yen et al., 2022). While this evidence is promising, there are significant gaps in the literature related to the potential of HRVB to prevent SUD relapse and how second-generation HRVB devices might support SUD recovery.

Phase II Studies Suggest Heart Rate Variability Biofeedback Can Ameliorate Negative Affect in Substance Use Disorder, but More Research is Needed to Determine If This Translates into Better Treatment Outcomes

The emerging literature on first-generation HRVB for SUD has demonstrated proof of concept (Phase I) and provided preliminary evidence for HRVB’s potential to mitigate cravings and potentially negative affect in individuals in SUD treatment (Phase II). However, few studies to date have examined SUD-related outcomes beyond craving. This is a major limitation of the existing literature that needs to be addressed in future studies. In addition to affective outcomes, future clinical trials should measure substance use outcomes, SUD symptom severity, and well-being. It will also be important to examine intervention effects over longer follow-up periods to determine the long-term effects of sustained HRVB. Additional research is also needed to better understand for whom HRVB is beneficial and under what conditions.

Ideally Phase III randomized-controlled trials will also be conducted, although there are inherent difficulties in creating a double-blind condition for a biofeedback intervention (Yucha & Montgomery, 2008). Further, HRVB will likely be best situated as an adjunct intervention supporting first-line SUD treatments like cognitive behavioral therapy, 12-step facilitation, and pharmacotherapy (Eddie et al., 2021; Leyro et al., 2019). That means a Phase III trial, wherein a new treatment or intervention is directly compared to a current gold-standard treatment, would not be appropriate. Challenges with funding will also likely be an issue, as most Phase III trials are funded by industry, and industry is not likely to fund a Phase III randomized-controlled trial for an existing intervention with limited capacity for patent protection.

Regardless of whether Phase III trials are conducted, a sufficient body of Phase II studies, when taken together, will provide sufficient information to determine HRVB’s efficacy for the treatment of SUD.

Second-Generation Heart Rate Variability Biofeedback Devices Need to be Tested in the Context of Substance Use Disorder Treatment

Second-generation, wearable HRVB devices that can function as just-in-time interventions have garnered much excitement in the field. While initial studies have demonstrated that brief exposure to resonance frequency or 6 breaths per minute breathing in the face of stress has positive effects on arousal, anxiety, and cognitive performance (Bates et al., 2019; Prinsloo et al., 2011; Wells et al., 2012), more studies are needed with SUD populations.

More Research is Needed to Identify Heart Rate Variability Biofeedback’s Mechanisms of Action

In addition to examining treatment outcomes and second-generation devices, a better understanding of HRVB’s mechanisms of action will inform how this intervention can be best utilized in clinical practice. HRVB may confer benefits for individuals with SUD through numerous neurobiological and physiological pathways. At a physiological level, HRVB increases parasympathetic nervous system activity and baroreflex sensitivity (Vaschillo et al., 2006), influences the arterial tone and related hemodynamics (Fonoberova et al., 2014), stimulates neural firing (Vaschillo et al., 2016), and improves gaseous exchange (Lehrer & Gevirtz, 2014), while also restoring autonomic function after exposure to physiological perturbation (Lehrer et al., 2010).

One theory posits that HRVB confers a benefit in SUD treatment by dampening visceral arousal through its effects on the baroreflex system (Bates et al., 2022), which provides an important neural pathway facilitating CAN integration of visceral information with cognitive and affective processes (Bates & Buckman, 2013).

Perhaps also as a function of baroreflex upregulation, 6 breaths per minute breathing has been shown to decrease activation in the visual cortices and increase activation in the brain stem and medial prefrontal areas during cue exposure, consistent with enhancement of higher-order, cognitive processing, and devaluation of sensory input (Bates et al., 2019). This has important implications for individuals with SUD for whom hyper-salience of alcohol and other drug cues can be a potent driver of substance use behaviors (Zilverstand et al., 2018).

It has also been suggested that substance use behaviors may be driven by bottom-up visceral reactions (Bechara, 2005; Paulus & Stewart, 2014) interacting with affective vulnerabilities, such as anxiety sensitivity and distress intolerance (Leyro et al., 2019). HRVB’s capacity to affect acute neurological and physiological change no doubt influences all these processes in unknown and discoverable ways.

Policy Implications

HRVB, and related 6 breaths per minute breathing, show promise for decreasing craving and other forms of negative affect in substance use disorder (SUD), suggesting they may be useful adjuncts to current first-line SUD treatments. Enthusiasm for these interventions is increased because they have no adverse side effects or contraindications, and they integrate well into existing treatments to address psychophysiological vulnerabilities not covered by first-line SUD interventions. Furthermore, the accessibility and scalability of second-generation HRVB interventions means this treatment tool has the potential to reach many individuals with limited access to formal treatment due to insurance barriers, lack of providers, or geographical isolation.

Given technological innovations in second-generation HRVB wearable devices and smartphone applications, clinical science has done much to increase HRVB accessibility. However, barriers to uptake remain. Currently, in the United States, most forms of biofeedback, including HRVB, are not covered by Medicare or Medicaid, nor are they typically covered by private health insurers. While more work is needed to fully determine the efficacy of HRVB for SUD, the evidence to date suggests this intervention can complement first-line SUD treatments, and sufficient evidence exists justifying HRVB as an intervention for several problems commonly co-occurring with SUD such as anxiety and depression.

Increasing access to HRVB through policy changes, such as requiring insurance reimbursement of HRVB, will empower individuals with a safe, low-cost treatment tool that addresses psychopathology at the level of the body as well as the brain. Further, once individuals are well practiced in resonance frequency or 6 breaths per minute breathing, they have this tool at their disposal at no cost to them, or to healthcare systems, for the rest of their life, likely improving public health and decreasing healthcare costs.

Conclusions

HRVB and closely related 6 breaths per minute breathing are biobehavioral interventions that support affective and behavioral self-regulation that can cover a critical gap in existing first-line substance use disorder (SUD) treatments. Given the potential impact of HRVB to boost treatment effects associated with first-line SUD treatments and promising preliminary data, funding support for this future research is well justified.

At a policy level, it is critical that barriers to HRVB uptake are addressed. Currently, in the United States, Medicare, Medicaid, and many private health insurance providers do not cover biofeedback-based interventions, greatly reducing the accessibility of this intervention. Improving access to HRVB makes sense because of the relatively low cost of delivering second-generation HRVB and its potential to improve public health, which would ultimately translate into cost savings for healthcare systems.

Key points.

  • Automatic physiological processes affected by substance use disorder (SUD) compromise effortful cognitive control and undermine attempts to avoid substance use.

  • While existing first-line treatments for SUD may indirectly help mitigate these vulnerabilities, none target them.

  • Heart rate variability biofeedback (HRVB) is a biobehavioral intervention involving rhythmic breathing that directly targets these deficits.

  • Phase I & II studies testing HRVB suggest it can mitigate craving when added to first-line SUD treatments.

  • More research is needed to determine if reductions in craving translate into reductions in substance use and SUD severity and enhanced well-being.

  • Currently, HRVB is not covered by most public and private insurances, greatly limiting access.

  • Policy changes increasing access to HRVB have the potential to improve public health and decrease healthcare costs.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the National Institute of Drug Abuse and National Institute on Alcohol Abuse and Alcoholism (grant numbers R24DA051988-02S1, K23AA027577-01A1, L30AA026135-02).

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

1.

The breathing frequency that produces optimal increases in HRV and baroreflex output is commonly referred to as the resonance frequency (Vaschillo et al., 2006). Resonance frequencies generally range from 0.075– to 0.108 Hz (4.5–6.5 breaths per minute), with previous work showing an average resonance frequency of 0.093 ± 0.007 Hz (5.5 ± 0.41 breaths per minute) in healthy adults (Vaschillo et al., 2006).

First generation HRVB was typically taught over 3–10 sessions and included formal assessment of patients’ resonance frequency at the beginning of treatment, initial breathing training using a pacer, introduction of biofeedback to guide breathing, and between-session daily practice (Lehrer et al., 2000).

Second-generation HRVB may include in-person HRVB training but is typically learned through a smartphone application with as needed tele-support. Patients are guided by a smartphone application that is either connected to a wearable biosensor (e.g., an electrocardiogram patch or smartwatch photoplethysmograph sensor) or uses the smartphone camera as a photoplethysmography sensor to display their HRV waveform. End-users are instructed by the app to rhythmically breathe so that they maximize their HRV, in essence allowing individuals to identify their resonance frequency without the need of a clinician.

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