January 2021 Issue
Diet’s Role in Opioid Recovery
By Carrie Dennett, MPH, RDN, CD
Today’s Dietitian
Vol. 23, No. 1, P. 42
Current Understandings and Research Limitations
Addiction to opioids is on the rise, and while substance use disorders may seem far removed from nutrition, the fact is some of the drug-related impacts on the body directly affect nutrition status and eating behaviors, which in turn influence health and well-being.
Opioids are natural or synthetic chemicals that interact with opioid receptors on nerve cells in the body and brain and reduce the intensity of pain signals and feelings of pain. They include the illegal drug heroin as well as synthetic opioids such as fentanyl—a prescription medication used for severe pain that’s significantly more potent than heroin—and other prescription pain medications such as oxycodone, hydrocodone, codeine, and morphine.
Although opioid pain medications generally are safe when taken for a short time, as prescribed by a health care professional, they do produce euphoria in addition to pain relief and therefore can be misused. Opioid use disorder is characterized by loss of control of opioid use, risky opioid use, impaired social functioning, tolerance, and withdrawal, and diagnosis is based on 11 symptoms defined in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders.1
Scope of the Opioid Use Disorder Problem
Legal opioids were overprescribed in the early 2000s for a variety of reasons, including aggressive marketing by drug manufacturers and the false belief that chronic pain protects against opioid misuse.2 In 2017, it was reported that 11.1 million people had misused prescription pain relievers in the previous year and 1.7 million people reported a prescription pain reliever use disorder. In that same timeframe, about 886,000 people reported heroin use, with about 652,000 people estimated to have a heroin use disorder. Only 54.9% of people with heroin use disorder and 28.6% with opioid use disorder received treatment at a specialty treatment facility.1 Even for those who do receive treatment for opioid use disorder, as many as 91% of patients relapse.2
Although legal when prescribed, fentanyl and other synthetic opioids also are illicitly manufactured and smuggled into the United States. These illicit opioids often are mixed with illegal substances such as heroin, but they’re also made into counterfeit prescription opioids or sedatives and sold on the street. This has driven the rapid increase in opioid overdose deaths in recent years.1 More than two-thirds of drug overdose deaths in recent years are due to opioids, and opioids were involved in 42,249 deaths in 2016—about five times higher than in 1999. That’s more than 115 deaths every day, on average, the majority of which were unintentional.3 While the overall drug overdose death rate declined slightly in 2018, it increased again in 2019.4
Limited Research
Unfortunately, high-quality research on the role of nutrition in opioid use disorder is lacking, says David Wiss, MS, RDN, CPT, owner of Los Angeles–based Nutrition on Recovery. A PubMed search confirms that. The primary reason is the challenge of doing research in this population, especially randomized controlled trials. “The challenge of creating high-quality research necessitates a control group,” Wiss says. He says it’s not enough to add foodservice and nutrition counseling at one treatment center, then measure outcomes. “Even that kind of study would not be considered high-quality research, because so many other factors could affect outcomes. You would have to have another center in the same organization that didn’t offer nutrition interventions, so you would have to have a multisite center. But once you’re splitting an organization into smaller subsets, you have smaller sample sizes.”
Wiss says not only would a quality research study be a very ambitious project, it would likely require a grant from the National Institutes of Health (NIH)—and the NIH doesn’t provide grants unless there’s already a good evidence base. “I think we’re getting closer to the point where that might be possible, but I don’t think there’s enough even low-quality evidence at this point for grant reviewers to look at,” he says.
Another issue is that opioid use disorder patients aren’t a homogenous group. “Not all people who have an opioid use disorder are the same. Some are more severe or ‘hard-core’ in the classic sense, which is a different case than someone who had a back injury, went on prescription opioids, and got dependent.” He also emphasizes that many people use—or misuse—more than one substance. “That makes it more difficult to identify specific substance-based interventions.”
Finally, disagreement about what a successful treatment outcome looks like can be a barrier to getting research funding. “Obviously, the outcome of interest to grant reviewers and funders is going to be abstinence,” Wiss says. “However, I think it’s safe to say there’s a lot of movement toward harm reduction ... focusing only on abstinence doesn’t always resonate with folks.” If someone’s no longer using prescription medication but is consuming alcohol, that would be an example of harm reduction.
Insurance Challenges
Even though nutrition therapy has benefits in opioid use disorder treatment for reversing nutrient deficiencies and promoting overall physical and mental health, dietitians are far from a fixture in treatment centers. “It’s not common, and I don’t anticipate it becoming common,” Wiss says. “As a practitioner, what I’ve noticed is that if insurance doesn’t cover it, it’s not likely to fit into the business model.” He says nutrition therapy and counseling seem to be a service that’s used only at higher-end centers that have more private-pay clients, while at lower-end centers patients are more likely to get food from food banks. “I don’t see that changing until there’s that high-quality research, which is unfortunate because when services like nutrition are offered only to individuals of higher socioeconomic status, it can increase the already present health disparities.”
Recovia, an Arizona-based outpatient treatment center that focuses on opioid dependency, chronic pain, and substance abuse, has included nutrition education since they opened five years ago, though they don’t have dietitians on staff, says clinical psychologist Devin Lincenberg, PsyD, Recovia’s program director. “I would love to have a dietitian on staff, if they could figure out how to get insurance to cover it,” she says, adding that it would be unfair for private-pay patients to have access to a dietitian, while those who rely on insurance don’t.
“A lot of places do value nutrition therapy, not necessarily because it will improve their outcomes, but because they have eating disorder clients that they don’t know what to do with,” Wiss says.
The Mental Health Angle
Co-occurring mental health conditions are common among individuals with substance use disorder,1 and Wiss says the greatest benefits for nutrition therapy in substance use disorder treatment may be under the broader umbrella of nutrition for mental health. He points to a growing evidence base for nutritional psychiatry and research showing that the Mediterranean diet can help reduce various mental health conditions.5,6 “We have good evidence that nutrition interventions can improve depressive symptoms and possibly anxiety-related disorders.”
In cases where sobriety and abstinence aren’t the only outcomes of interest, researchers and clinicians can start looking at quality of life, Wiss says. “I think that measuring posttraumatic stress disorder [PTSD] symptoms, anxiety symptoms, and depression symptoms holds a lot of promise,” he says, adding that nutrition therapy may be able to reduce some of the major prescription care, although this is controversial. “Medication use can become excessive in early recovery, especially when there are not other lifestyle measures such as nutrition and exercise. It’s not uncommon for someone in early recovery to be on three to five medications. One of the major messages of nutritional psychiatry is that nutrition imbalances should be addressed before going to medication.”
Major Nutrition Impacts
As with other substance use disorders, opioid use disorder can lead to malnutrition, nutrient deficiencies, metabolic disorders that compromise nutrition, and altered body composition.7
Nutrient Deficiencies
Malnutrition is a general concern with substance use disorders not only because of inadequate nutrient intake—whether due to poor appetite, choosing drugs instead of food, or general food insecurity—but because the substance may interfere with nutrient metabolism.7
Much of the nutrition-related data on the impact of opioid use disorder comes from observations of patients being treated with methadone. Opioid use disorder has been associated with decreased levels of several micronutrients, including vitamin C, potassium, selenium, zinc, calcium, magnesium, and several B vitamins.8 Chronic opioid abuse can lead to deficiencies in folate, which can play a role in developing colon cancer and liver disease, and vitamin B3, which can lead to pellagra. Symptoms of pellagra include diarrhea, mental disorientation, and depression. Protein-energy malnutrition also is common.7,9 Lower than normal bone mass is another concern, in part due to deficiencies in nutrients necessary for bone health.8
Just as opioid use has increased, so has opioid use during pregnancy. In addition to the toxic effects of opioid abuse on the developing fetus, opioid use disorder–related nutrition deficiencies during pregnancy are of particular concern. Adequate nutrition and healthy weight gain are critically important, especially adequate intake of iron and folate for fetal growth and prevention of neural tube defects.10,11
Gastrointestinal Concerns
Opioids delay gastric emptying, often resulting in constipation-related symptoms such as straining, hard stools, and painful, infrequent and incomplete bowel movements. Other symptoms associated with opioid use include heartburn, nausea, vomiting, chronic abdominal pain, and bloating. Slowed intestinal motility also may create an intestinal environment that favors bacterial growth. One large retrospective hospital-based study found that moderate to high use of opioids was associated with increased risk of Clostridium difficile infection, with the greatest risk at the highest use levels.8
These gastrointestinal imbalances contribute to systemic inflammation and impaired immune system function, possibly due to impaired gut barrier function, also known as leaky gut. When the tight junctions between the epithelial cells lining the intestines don’t function properly, bacteria can escape the intestine and enter the portal circulation, where they can travel to the liver.8 The liver is the organ most affected by opioid use due to gut permeability and inflammation.9,12
Wiss says gastrointestinal distress tends to resolve itself with time, although in some cases dysbiosis can be persistent, particularly if someone isn’t eating enough dietary fiber. “In a residential detox setting, there seems to be some normalization in bowel function in those first weeks and months,” he says. “Not that some additional nutrition intervention isn’t warranted, but sometimes it’s a turnoff if this information is presented too soon, for example during detox.”
Metabolic Concerns
Opioid use disorder also is associated with low cholesterol levels, but research in former heroin users finds that they tend to have higher cholesterol.8 This may be due in part to increased consumption of comfort foods high in refined carbohydrates, such as pastries, cookies, and sugar-sweetened cereals, which also happen to be easier to digest if someone is experiencing gastrointestinal distress. In addition, opioid use can contribute to insulin resistance, possibly caused by beta cell dysfunction. In particular, research has found that fasting insulin levels were four times higher in people with heroin addiction, yet insulin response was 42% lower and the clearance rate of glucose from the bloodstream was 80% lower.13
Eating Behaviors and Weight Concerns
Opioid use disorder is associated with high sugar consumption and low intake of dietary fiber.9 Patients on methadone treatment tend to crave sugar, eating more sugary foods and fewer fruits, vegetables, fish, and fiber-rich foods.14
Many people with a history of substance use disorders may have low distress tolerance and therefore be more likely to eat in response to uncomfortable emotions.15 Wiss says the overlap between eating disorders and substance use disorders is anywhere from 3% to 50%, or even higher depending on how things are measured, resulting in purging, binging, or food addiction–like behaviors. “Many people with opioid use disorder had disordered behaviors before, and the drug use made those behaviors go away,” he says. “Then, in recovery, they roar back.” Other patients develop disordered eating behaviors for the first time in recovery, he says, as they swap their substance addiction for addictive behaviors related to food.16
PTSD, low socioeconomic status, and history of childhood trauma may be higher among patients with opioid use disorder, and Wiss stresses that early life adversity impacts eating behavior over the lifespan.17 “Given that people with early life adversity are at high risk of substance use disorder, it’s safe to assume that this relationship between substance use disorders and eating disorders is likely to play out in early recovery, and therefore treatment models must be trauma informed,” Wiss says. “This includes being nonjudgmental and nonpunitive and emphasizing a do-no-harm approach.”
Many patients receiving methadone for opioid addiction gain a significant amount of weight.16 For some patients, this could be due to improved food intake and normalization of metabolism,7 while for others it may be due to altered glucose metabolism or dysfunctional eating behaviors.16 This is often followed by distress about the weight gain.8 In one study of 297 women, 43% expressed concern that weight gain could trigger drug relapse.18 Weight gain during treatment is more likely to be a concern if there are underlying body image issues.15 Wiss agrees that gaining a significant amount of weight in recovery could trigger a relapse, although this risk may vary based on age and gender. “I think a 25-year-old girl who gained 30 lbs might be more likely to relapse than a middle-aged male,” he says, adding that men can have body image issues, too. “There should be safe places for people to discuss body image during treatment.”
Recovia uses an evidence-based psychoeducational curriculum to help patients understand how physical and emotional well-being may affect food choices, and vice versa. “If a patient is undergoing a life stressor, this could affect their food choices, and food choices can impact how the body and mind feel,” Lincenberg says. Recovering from an addiction is certainly stressful in and of itself, but patients also may be experiencing depression and anxiety, in addition to withdrawal symptoms.
Lincenberg says her staff addresses the idea of nutritious food as fuel for the body and helps patients find ways to cope that don’t necessarily involve food. However, if someone is just beginning the heroin addiction recovery process, they won’t be told that they shouldn’t cope with food. Addressing emotional eating or addiction swapping may come later in the process once the patient is stabilized. She says the goal is more than just treating the addiction; it’s about their overall physical and mental health. “We treat patients using a biopsychosocial model, a complete mind-body approach. A lot of what we look for are trends in their behavior, and then we address that.”
Dietary Interventions
Patients undergoing treatment from opioid use disorder can benefit from a protein-rich diet (1.2 to 2 g/kg/day) supplemented with whey- or plant-based protein powder if necessary. Fresh, frozen, and dried fruit can help satisfy a sweet tooth more healthfully. To address micronutrient imbalances, a multivitamin/mineral supplement divided into two doses daily is recommended, along with vitamin D3 if needed to correct a deficiency. There’s also evidence to support DHA-rich omega-3 fatty acids (3 g/day) and a probiotic supplement.8
It’s important to note there’s a significant amount of fraud related to opioid recovery, some from shoddy treatment facilities participating in insurance fraud, and others from companies marketing dietary supplements as opioid withdrawal aids. The FDA has warned consumers not to use products containing Mitragyna speciosa, commonly known as kratom, because of safety concerns,19,20 and has issued warning letters to marketers and distributors about kratom products.21 The FDA has taken similar action regarding products containing tianpetine, an antidepressant drug that’s been marketed as a dietary ingredient, although it doesn’t meet that definition. Tianpetine itself may be addictive.22
In December 2017, the Center for Science in the Public Interest identified eight companies marketing products described as natural opioid withdrawal aids—all primarily composed of various combinations of vitamins, minerals, and herbal ingredients—and contacted them to ask whether they could point to scientific studies showing that their products were more effective than placebo. The companies could not.23
— Carrie Dennett, MPH, RDN, CD, is the nutrition columnist for The Seattle Times, owner of Nutrition By Carrie, and author of Healthy for Your Life: A Holistic Guide to Optimal Wellness.
References
1. U.S. Department of Health & Human Services. Facing addiction in America: the Surgeon General’s spotlight on opioids. https://addiction.surgeongeneral.gov/sites/default/files/Spotlight-on-Opioids_09192018.pdf. Published September 2018.
2. Hakimian JK, Dong TS, Barahona JA, et al. Dietary supplementation with omega-3 polyunsaturated fatty acids reduces opioid-seeking behaviors and alters the gut microbiome. Nutrients. 2019;11(8):1900.
3. Wilson N, Kariisa M, Seth P, Smith H IV, Davis NL. Drug and opioid-involved overdose deaths — United States, 2017–2018. MMWR Morb Mortal Wkly Rep. 2020;69(11):290-297.
4. Ahmad FB, Rossen LM, Sutton P; National Center for Health Statistics. Provisional drug overdose death counts. Centers for Disease Control and Prevention website. https://www.cdc.gov/nchs/nvss/vsrr/drug-overdose-data.htm. Updated November 12, 2020.
5. Marx W, Moseley G, Berk M, Jacka F. Nutritional psychiatry: the present state of the evidence. Proc Nutr Soc. 2017;76(4):427-436.
6. Parletta N, Zarnowiecki D, Cho J, et al. A Mediterranean-style dietary intervention supplemented with fish oil improves diet quality and mental health in people with depression: a randomized controlled trial (HELFIMED). Nutr Neurosci. 2019;22(7):474-487.
7. Jeynes KD, Gibson EL. The importance of nutrition in aiding recovery from substance use disorders: a review. Drug Alcohol Depend. 2017;179:229-239.
8. Wiss D. Chapter 2 - the role of nutrition in addiction recovery: what we know and what we don't. Assess Treat Addict. 2019;21-42.
9. Szczepaniak A, Fichna J, Zielińska M. Opioids in cancer development, progression and metastasis: focus on colorectal cancer. Curr Treat Options Oncol. 2020;21(1):6.
10. Nagarajan MK, Goodman D. Not just substance use: the critical gap in nutritional interventions for pregnant women with opioid use disorders. Public Health. 2020;180:114-116.
11. Sebastiani G, Borrás-Novell C, Casanova MA, et al. The effects of alcohol and drugs of abuse on maternal nutritional profile during pregnancy. Nutrients. 2018;10(8):1008.
12. Verna EC, Schluger A, Brown RS Jr. Opioid epidemic and liver disease. JHEP Rep. 2019;1(3):240-255.
13. Nabipour S, Ayu Said M, Hussain Habil M. Burden and nutritional deficiencies in opiate addiction — systematic review article. Iran J Public Health. 2014;43(8):1022-1032.
14. Mysels DJ, Sullivan MA. The relationship between opioid and sugar intake: review of evidence and clinical applications. J Opioid Manag. 2010;6(6):445-452.
15. Wiss DA, Schellenberger M, Prelip ML. Registered dietitian nutritionists in substance use disorder treatment centers. J Acad Nutr Diet. 2018;118(12):2217-2221.
16. McDonald E, Laurent J. Hedonic eating behaviors and food preferences associated with medication-assisted treatment for opioid use disorder. J Opioid Manag. 2019;15(6):487-494.
17. Wiss DA. A biopsychosocial overview of the opioid crisis: considering nutrition and gastrointestinal health. Front Public Health. 2019;7:193.
18. Warren CS, Lindsay AR, White EK, Claudat K, Velasquez SC. Weight-related concerns related to drug use for women in substance abuse treatment: prevalence and relationships with eating pathology. J Subst Abuse Treat. 2013;44(5):494-501.
19. FDA and kratom. U.S. Food & Drug Administration website. https://www.fda.gov/news-events/public-health-focus/fda-and-kratom. Updated September 11, 2019.
20. Eggleston W, Stoppacher R, Suen K, Marraffa JM, Nelson LS. Kratom use and toxicities in the United States. Pharmacotherapy. 2019;39(7):775-777.
21. FDA takes action on products marketed as dietary supplements containing tianpetine and warns consumers. U.S. Food & Drug Administration website. https://www.fda.gov/food/cfsan-constituent-updates/fda-takes-action-products-marketed-dietary-supplements-containing-tianpetine-and-warns-consumers. Updated November 20, 2018.
22. El Zahran T, Schier J, Glidden E, et al. Characteristics of tianeptine exposures reported to the National Poison Data System — United States, 2000–2017. MMWR Morb Mortal Wkly Rep. 2018;67(30):815-818.
23. Crackdown urged on supplements marketed as opioid withdrawal aids: CSPI investigation shows manufacturers can’t support claims. Center for Science in the Public Interest website. https://cspinet.org/news/crackdown-urged-supplements-marketed-opioid-withdrawal-aids-20171208. Published December 8, 2017.