In the past three decades, we have seen considerable advances in the treatment of substance use disorder (SUD). Psychosocial interventions such as cognitive-behavioral therapy (CBT) are effective; however, maintaining the gains made during SUD treatment is a challenge for the majority of individuals. While CBT focuses on cognitions and behaviors associated with substance use, such treatments do not fully address other important factors contributing to relapse, such as affect dysregulation and craving, which are mediated by physiological as well as cognitive processes.
Recent research from David Eddie, PhD, Associate Director of Clinical Translational Recovery Science at the Recovery Research Institute at Mass General, has explored how biobehavioral interventions like heart rate variability (HRV) biofeedback can complement existing therapies by directly targeting the physiological underpinnings of affect regulation and craving.
Heart Rate Variability and SUD
Heart rate variability (HRV) reflects the variance in intervals between consecutive heartbeats and serves as a non-invasive biomarker of autonomic nervous system function and physiological adaptability. Higher HRV levels reflect greater regulatory capacity in the brain, autonomic nervous system, and cardiovascular systems.
Chronic substance use, especially heavy alcohol intake, is consistently associated with diminished HRV, and previous research indicates that lower HRV predicts vulnerability to SUD relapse. Recent work from Eddie’s research team demonstrated that individuals in early SUD recovery with lower HRV are more likely to lapse to substance use, underscoring HRV’s prognostic value.
While lower HRV may signal vulnerability for substance use, research by Eddie and colleagues has also examined interventions that enhance regulatory capacity and, in this way, reduce relapse risk. HRV biofeedback is a biobehavioral intervention that trains individuals to breathe at their personalized resonance frequency, leading to large acute increases in HRV. This strengthens bidirectional brain-body signaling, enhancing and restoring flexibility in neural communication pathways that modulate stress responsivity and emotion regulation. By targeting these neurocardiac regulatory mechanisms, HRV biofeedback is thought to address self-regulatory vulnerabilities not typically engaged by cognitive or peer-support interventions, potentially offering unique adjunctive benefits for individuals with SUD.
RCT of HRV Biofeedback in Adults with SUD
With HRV biofeedback, participants learn to adjust their breathing in ways that directly influence HRV. First-generation HRV biofeedback was delivered in the clinic and used handheld practice devices. While many studies indicated a benefit of first-generation HRV biofeedback, it was expensive to deliver and generally not easy to access in the community. Second-generation HRV biofeedback, however, takes advantage of wearable technology (see the photo to the right) that is more affordable, doesn’t require a clinician to deliver the treatment, and allows for individualized, adaptive HRV biofeedback practice. An additional benefit of these newer devices is that they can sense stress in real-time and prompt wearers to do brief bursts of HRV biofeedback to offset this stress.
In a study published in JAMA Psychiatry, Eddie and colleagues conducted a phase 2 randomized clinical trial examining the impact of wearable second-generation HRV biofeedback on negative affect, positive affect, craving, and use of alcohol and other drugs.
In this trial including 115 treatment-seeking adults with SUD, second-generation HRV biofeedback plus standard care was compared to standard care alone. Among study participants (69 female [60.0%]; mean age, 46.18 [SD 11.59] years), HRV biofeedback was associated with significant reductions in negative affect and craving over 8 weeks. In contrast, the group receiving standard care alone experienced increases in both negative affect and craving.
In addition, HRV biofeedback was also associated with a 64% reduction in alcohol or other drug use days (odds ratio [OR], 0.36; 95% credible interval [CrI], 0.25-0.54) compared to controls. The intervention also weakened the relationship between craving and subsequent substance use, such that those receiving HRV biofeedback were less likely to use alcohol or other drugs following craving. No significant differences were seen for positive affect.
HRV Biofeedback: A Promising Adjunct to Standard Care
This study extends previous clinical findings supporting the utility of HRV biofeedback in individuals with SUD. Consistent with previous trials, this study confirms HRV biofeedback’s capacity to reduce negative affect and craving in individuals with SUD; however, this study is among the first to show that this intervention leads to clinically meaningful reductions in the use of alcohol and other drugs. The effect size was robust; compared to controls, use of HRV biofeedback was associated with a 64% lower probability of alcohol or other drug use on a given day.
In addition to the clinical benefits, HRV biofeedback is particularly attractive because it is easy to learn, has no side effects, and has no contraindications. The current study was the first RCT to test second-generation wearable HRV biofeedback technology for SUD. Wearable HRV biofeedback technology connected to smartphone applications presents many advantages over first-generation HRV biofeedback, increasing accessibility to treatment and decreasing patient burden.
In addition, second-generation HRV biofeedback may offer specific clinical benefits. While previous work indicates that regular daily HRV biofeedback practice is beneficial, wearable HRV biofeedback allows individuals to monitor HRV in real-time and can prompt wearers to engage in brief bursts of HRV biofeedback practice in the moment, when they are experiencing heightened levels of distress. The authors hypothesize that HRV biofeedback may confer the greatest benefit when used strategically to manage acute bouts of craving.
This study establishes wearable HRV biofeedback as a promising adjunctive strategy for SUD, conferring measurable reductions in negative affect and craving, and facilitating recovery by bolstering self-regulation and resilience against SUD relapse.
Read More
Eddie D, Nguyen M, Zeng K, Mei S, Emery N. Heart Rate Variability Biofeedback for Substance Use Disorder: A Randomized Clinical Trial. JAMA Psychiatry. 2025 Oct 1:e252700.
Eddie D, Price JL, Bates ME, Buckman J. SUBSTANCE USE AND ADDICTION AFFECT MORE THAN THE BRAIN: THE PROMISE OF NEUROCARDIAC INTERVENTIONS. Curr Addict Rep. 2021 Sep;8(3): 431-439.
Eddie D, Wieman S, Pietrzak A, Zhai X. In natura heart rate variability predicts subsequent alcohol use in individuals in early recovery from alcohol use disorder. Addict Biol. 2023 Aug; 28(8):e13306.
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Dr. David Eddie is the Associate Director of Clinical Translational Recovery Science at the Recovery Research Institute and Center for Addiction Medicine, a clinical psychologist in Massachusetts General Hospital’s Department of Psychiatry, and an assistant professor at Harvard Medical School. His research seeks to better understand the psychological and psychophysiological causes and conditions that lead to people becoming addicted to alcohol and other drugs, and how these factors can also maintain addiction. He uses this knowledge to develop and study novel treatments for substance use disorder.
