Download Substance Use Disorders Grand Rounds

Substance Use Disorders
Grand Rounds
Department of Alcohol & Drug Services
A quarterly newsletter for the health care professional
A p u b l ic a t io n o f t h e Sa n t a Cl a r a Co u n t y
Dep a r t m en t of Alc o h o l & Dr u g Ser v i c es
Vol . 9
J an / M ar 2 0 13
The Importance of Nutrition in Recovery From
Substance Use Disorders
Margaret Williams, MS, RD
Ricardo Martinez, BS
After twenty years of polysubstance abuse, 39 year old Alex* has been clean and sober for six months, due to
his own efforts, the medical staff at VMC, his treatment counselor, NA meetings and his sponsor. He also
states he is grateful that the VMC doctor screened for drug or alcohol use – otherwise he would not have disclosed his substance use because he thought he was a “hopeless case”. After 6 months of treatment, Alex
now knows that good nutrition, relaxation, and exercise all play an important role in long term recovery. Alex’s
treatment team wants him to stay healthy and substance free for the rest of his life.
So, where does optimal nutrition come in to play with regards to recovery from substance use disorders?
To assist in the recovery process, it is important for the professional to understand the impact of nutrition on the
physical and mental health of the client. Practitioners working with recovering addicts have repeatedly found
that when the client is following the principles of good nutrition, he or she is medically healthier and has fewer
symptoms of withdrawal and cravings. A 2004 study by the American Dietetic Association (ADA) concluded
that patients who receive nutrition education and intervention in tandem with an addiction recovery program
have faster recovery periods and decreased chances of relapse (1). Social, emotional, physical, economic
and nutritional factors all come into consideration when assessing and planning appropriate treatment options.
Let’s look at some Frequently Asked Questions (FAQ) regarding Nutrition and Recovery:
FAQ #1
Generally speaking, what’s the main nutrition issue with which I can help my client who is in recovery
from substance use disorders (SUD)?
Alcohol and drugs can prevent the body from sustaining and breaking down nutrients and releasing toxins. This
results in health issues including malnutrition. Most individuals with SUD have at least two or more nutritionrelated health issues, such as iron deficiency anemia, chronic diarrhea/constipation, and/or high or low Body
Mass Index (BMI). These issues can be caused by the particular drug of choice, poor dietary intake, lack of
food resources, poor food choices or altered nutrient metabolism. Nutritionally speaking, most substance abusers need small periodic meals throughout the day consisting of good quality protein, complex carbohydrates,
fiber, fats and low calorie fluids. A good recovery daily diet includes 25-30 percent of high quality protein, 25-30
percent healthy fat, 45 percent of mostly complex carbohydrates, and 30 gm fiber to make up a total of 2,000 2400 calories per day, fairly close to the USDA Food Guide Pyramid. The client often needs snacks, especially during the early stages of recovery to avoid erratic blood sugars and to avoid cravings.
*True name withheld
FAQ #2
What do brain chemistry, food, and addiction have in common?
In order for the brain to process information correctly, the chemical messengers (neurotransmitters) must function
normally. Drugs and alcohol stimulate these neurotransmitters, but addiction eventually depletes them. Most addictive substances change the way the brain responds, via neurotransmitters, to pleasure or pain. Brain chemistry
altered by drugs or alcohol can override one’s normal appetite and food may no longer appeal to the client as it
once had. As a result, the addict does not eat, food does not taste good, or there is no pleasure in eating. But,
food and good nutrition feed a healthy brain. It’s a vicious cycle. The more nutritionally compromised a person is
by not eating well, the worse it is for brain chemistry and neurotransmitters.
FAQ #3
Nutritionally, how can a person in recovery improve his/her altered neurochemistry?
This is an important question because if neurochemicals are stabilized, there is less risk for cravings and relapse.
SUD diminishes the body’s ability to properly process two important amino acids: tyrosine and tryptophan. These
amino acids are responsible for the production of the neurotransmitters norepinephrine, dopamine, and serotonin.
These compounds are essential for emotional stability, mental clarity, and a general state of well-being. Decreased
levels of these neurotransmitters negatively affect mood and behavior. Tyrosine is a precursor to the neurotransmitters norepinephrine and dopamine (chemical messengers that promotes mental acuity and alertness). It is a
nonessential amino acid found in protein-rich foods such as meat, poultry, seafood and tofu. Tryptophan, found in
foods such as bananas, milk and sunflower seeds and turkey, is integral to the production of serotonin, which has
a calming effect and is important for adequate sleep. Some studies have shown that the Omega-3 Fatty Acids that
are found in fish and flax can increase the brain cells’ ability to take in serotonin (2). Food for thought!
FAQ #4
What about food, mood and relapse?
According to most clients, anger and/or stress is associated with a greater likelihood for relapse. Food can affect
mood. Along with altered amino acids (building blocks of protein and neurotransmitters), deficiencies of nutrients
like folic acid and other B-complex vitamins can have a serious and negative impact on mood and recovery. Sugar
and caffeine can contribute to mood swings, so an intake of both should be reduced during the early stages of recovery. Often, that’s hard to do, especially if self-help meetings offer coffee and/or high sugar foods which recovering addicts/alcoholics can crave.
FAQ #5
Any suggestions of specific substances of abuse and nutrition?
Certainly different substances cause a variety of nutrition challenges. The major substance of abuse are alcohol,
opioids, stimulants and marijuana.
Alcoholism is one of the major causes of nutritional deficiency in the United States. The most common deficiencies are of pyridoxine (vitamin B6), thiamine, and folic acid. A lack of these nutrients causes anemia and nervous
system (neurologic) problems. Korsakoff's syndrome ("wet brain") occurs when heavy alcohol use causes a lack of
enough thiamine. Alcohol intoxication also damages two major organs involved in metabolism and nutrition: the
liver and the pancreas. The liver removes toxins from harmful substances. The pancreas regulates blood sugar
and the absorption of fat. Damage to these two organs results in an imbalance of fluids, calories, protein, and
electrolytes. Many alcoholics present severe malnutrition, as alcohol’s metabolic process prevents the body from
proper absorption, digestion, and use of essential nutrients and vitamins (3), specifically the fat soluble vitamins (A,
E, and D) and the water soluble vitamins thiamine (B1), riboflavin (B2), pyridoxine (B6) and ascorbic acid (C).
Even if an alcohol dependent person is eating optimally, he/she may still show nutritional deficiencies. Severe alcohol abusers may already have chronic liver failure. This presents a major obstacle because it causes decreased
protein metabolism. Chronic liver failure leads to decreased protein production in the liver (albumin, coagulation
factors, serum α1-antitrypsin); decreased synthesis of urea; and decreased metabolism of aromatic amino acids.
Grand Rounds Newsletter
Page 2
An adequate diet in many cases can control chronic liver disease and prevent the onset of cirrhosis caused by excessive alcohol consumption. It’s best to refer the patient to a Registered Dietitian for a full nutrition assessment to
ensure individualized nutrition care (4).
OPIATES
Opiates (including codeine, vicodine, oxycontin, heroin, and morphine) affect the gastrointestinal system. Constipation is a very common symptom of abuse. Symptoms that are common during opiate withdrawal include diarrhea, nausea, vomiting. These symptoms may lead to a lack of enough nutrients and an imbalance of electrolytes
(such as sodium, potassium, and chloride). Eating balanced meals may make these symptoms less severe
(however, eating can be difficult due to nausea). A diet high in fiber with plenty of complex carbohydrates (whole
grains, vegetables, peas, and beans) along with a low fat protein intake (fish, chicken or eggs) is recommended.
STIMULANTS
Stimulant use (cocaine, methamphetamine) reduces appetite and can lead to weight loss, compromised dental
health (meth mouth) and poor nutrition. Abusers of these drugs may stay awake for days at a time. Dehydration
and electrolyte imbalances can occur during these episodes. Returning to a normal diet can be difficult if a person
has lost a significant amount of weight. Memory problems and faulty hunger cues, which are a complication of
long-term stimulant use, can contribute to lack of meal planning and scheduling.
Again, regaining general good nutrition (see Guidelines below) is essential for the optimal recovery process. Be
aware that clients, particularly female clients, may gain quite a bit of weight in recovery and this weight gain may
be a relapse trigger .
MARIJUANA (cannabinoids)
Marijuana use increases appetite. Some long-term users may be overweight and need to cut back on fat, sugar,
and total calories to reach a healthy BMI.
FAQ #6
Should I recommend any special vitamin or mineral to my patient who is recovering from SUD?
Patients with alcohol addiction should supplement with vitamin A, or consume foods rich in vitamin A, such as
sweet potato, carrots, and dark leafy greens. For patients with illicit drug abuse problems a multivitamin is generally prescribed (though not always imperative) to replenish energy levels. Protein and or a multivitamin supplements can be recommended, depending on the health of the patient (5). But remember, by and large, real food
that has to be chewed is the best absorbed and metabolized.
When people in recovery feel better, they are less likely to start using alcohol and drugs again. Because balanced
nutrition helps improve mood and health, it is important to encourage a healthy diet. However, people who are recently clean and sober may not be ready to make other drastic lifestyle changes, such as dietary or exercise modifications . It is more important that clients avoid returning to substance abuse than that they stick to a strict diet.
General Guidelines
Stick to regular mealtimes
Eat a low-fat diet
Get more protein, complex carbohydrates, and dietary fiber
Vitamin and mineral supplements may be helpful during recovery (this may include B-complex, zinc, and
vitamins A and C)
Grand Rounds Newsletter
Page 3
CONCLUSION
Keep in mind, like most chronic diseases, a single treatment, such as nutrition therapy, is not solely effective for
treating substance use disorders but can be an essential start and recent studies indicate that nutrition intervention plays a pivotal role in a successful substance use recovery journey.
People with SUD’s are more likely to relapse when they have poor eating habits. This is why regular meals and
increased fluids (to avoid dehydration) are so important. Clients with SUD’s often forget what it's like to be hungry or thirsty and instead think of these feelings as a drug or alcohol cravings. Alex*, has followed the following
nutrition recommendations of his treatment team and is confident in his continued recovery lifestyle.
Increasing the odds of a lasting and healthy recovery:
Eat nutritious meals and snacks. Drink plenty of low calorie fluids.
Get physical activity and enough rest.
Reduce simple sugars, caffeine and stop smoking, if possible.
Seek help from a Registered Dietitian, Licensed Therapist, or support group on a regular basis.
Consider nutrition supplementation or multivitamins.
REFERENCES
1
Nutrition Education Is Positively Associated with Substance Abuse Treatment Program Outcomes Louis P
Grant, MS, RD; Betsy Haughton, EdD, RD; Dileep S. Sachan, PhD
2
http://bjp.rcpsych.org/content/181/1/22.full
3
Relationships Between Nutrition, Alcohol Use, and Liver DiseaseCharles S. Lieber, M.D., M.A.C.P.
4
Links between Nutrition, Drug Abuse, and the Metabolic Syndrome Ashraf Virmani, Zbigniew Binienda,
Syed Ali, Franco Gaetani
5
http://www.drugabuse.gov/drugs-abuse/commonly-abused-drugs/health-effects
ABOUT THE AUTHORS
Margaret Williams, MS, RD has worked for the county for 25 years, 14 of those years were in providing education and outreach at DADS in the Addiction Medicine and Therapy division and Perinatal Substance Abuse
Program..
Ricardo Martinez has a BS Degree in Nutritional Science from UC Davis and is employed by Santa Clara
County’s Public Health Department, WIC Program.
Contact The Santa Clara County Dept of Alcohol & Drug Services
For comments or feedback about the field of alcohol and drug abuse or about training services for your clinic
or agency, contact Bruce Copley, DADS Director: [email protected]
For comments or questions about this and other newsletters, or if you have ideas for future newsletter topics,
contact Mark Stanford, Ph.D., Editor of the Grand Rounds newsletter and Director of the DADS Addiction
Medicine & Therapy division: [email protected].
To get previous issues of the Substance Use Disorders Grand Rounds newsletter,
visit the DADS website at www.sccdads.org