"Nutrition Interventions Amidst an Opioid Crisis: The Emerging Role of the RDN" by David Wiss MS RDN

1. Nutrition Interventions Amidst an Opioid Crisis: The Emerging Role of the RDN David Wiss MS RDN October 21, 2018

2. David Wiss MS RDN All rights reserved Disclosures & Affiliations Doctoral Student (PhD) UCLA Fielding School of Public Health Community Health Sciences Department Advisor: Dr. Michael Prelip David Wiss MS RDN Founder & Owner Nutrition in Recovery LLC (Los Angeles, CA)

3. David Wiss MS RDN All rights reserved Learning Outcomes At the end of today’s session, participants will be able to… 1) Describe the impact of opioids on nutritional status and gastrointestinal health. 2) Identify common disordered and dysfunctional eating patterns common to opioid-addicted populations. 3) Implement nutrition therapy protocols for specific substances including opioids and for polysubstance abuse.

4. David Wiss MS RDN All rights reserved GOT THEORY? BIOPSYCHOSOCIAL MODEL Dr. George Engel (late 1970s) GENERAL SYSTEMS THEORY (1950s) Aims to unify knowledge and theories across different disciplines into a systemic vision of a “better world”

7. David Wiss MS RDN All rights reserved BIOPSYCHOSOCIAL – OPIOIDS Three Interacting Perspectives: 1. Environmental factors • Supply-side • Access & exposure 2. Psychosocial factors • Stress • Trauma/PTSD • Adverse childhood experiences 3. Biological factors • Genetics & reward pathways • Epigenetics & microbiome • Nutrition??? Moderating & Mediating Factors: Life Course Theory Socioeconomic Status Behavioral Economics Neuroeconomics

8. David Wiss MS RDN All rights reserved OPIOIDS: “PUBLIC HEALTH EMERGENCY” • 2000-2014 • More than half a million died from drug overdose1 • 61% from opioids1 • Higher prevalence: • Rural (vs. urban)2 • Whites (vs. non)3 • Growing risk in adolescents4 1.Rudd, Aleshire, Zibbell, and Gladden. 2016. “Increases in Drug and Opioid Overdose Deaths — United States, 2000–2014.” MMWR. Morbidity and Mortality Weekly Report 64(50–51):1378–82. 2. Dunn et al. 2016. “Opioid Overdose Experience, Risk Behaviors, and Knowledge in Drug Users from a Rural versus an Urban Setting.” Journal of Substance Abuse Treatment 71:1–7. 3. Martins, Sarvet, et al. 2017. “Changes in US Lifetime Heroin Use and Heroin Use Disorder: Prevalence From the 2001-2002 to 2012-2013 National Epidemiologic Survey on Alcohol and Related Conditions.” JAMA Psychiatry. 4. Sheridan et al. 2016. “Association of Overall Opioid Prescriptions on Adolescent Opioid Abuse.” The Journal of Emergency Medicine 51(5):485–90.

10. David Wiss MS RDN All rights reserved PAIN MANAGEMENT • 2001 Joint Commission • Fifth “vital sign” • Regulatory pressure • Dual epidemic1 1. Abuse 2. The “right” to control poorly defined pain • Psychosomatic pain? • Emergency departments2 • Misuse and diversion 1. Pergolizzi, LeQuang, Berger, and Raffa. 2017. “The Basic Pharmacology of Opioids Informs the Opioid Discourse about Misuse and Abuse: A Review.” Pain and Therapy 6(1):1–16. 2. Lyapustina et al. 2017. “The Contribution of the Emergency Department To Opioid Pain Reliever Misuse And Diversion: A Critical Review.” Pain Practice 17(8):1097–1104. Brady, McCauley, and Back. 2016. “Prescription Opioid Misuse, Abuse, and Treatment in the United States: An Update.” American Journal of Psychiatry 173(1):18–26.

11. David Wiss MS RDN All rights reserved PRESCRIPTION OPIOIDS HEROIN • 50% of patients taking prescription opioids beyond 12 weeks still using them after 5 years1 • 2010 OxyContin released abuse-deterrent formula • Heroin use began to rise2 • 2010-2014 • Heroin-related deaths tripled in the US3 1. Martin et al. 2011. “Long-Term Chronic Opioid Therapy Discontinuation Rates from the TROUP Study.” Journal of General Internal Medicine 26(12):1450–57. 2. Cicero and Ellis. 2015. “Abuse-Deterrent Formulations and the Prescription Opioid Abuse Epidemic in the United States: Lessons Learned From OxyContin.” JAMA Psychiatry 72(5):424–30. 3. Rudd, Aleshire, Zibbell, and Gladden. 2016. “Increases in Drug and Opioid Overdose Deaths — United States, 2000–2014.” MMWR. Morbidity and Mortality Weekly Report 64(50–51):1378–82.

13. David Wiss MS RDN All rights reserved SUPPLY-SIDE PROBLEM? (ENVIRONMENTAL THEORY) • Big Pharma aggressively marketed addictive products to physicians • Over-prescription • “Pill mills” • Roughly half of heroin users started with prescription opioids1,2 • Is it simply a matter of reducing supply?

15. David Wiss MS RDN All rights reserved MEDICATION ASSISTED TREATMENT • Methadone • Buprenorphine (Subutex) • Buprenorphine + naloxone (Suboxone) • Naloxone (Narcan) • Reverse the effect of overdose • Naltrexone • Relapse prevention

17. David Wiss MS RDN All rights reserved SUPPLY-SIDE THEORY (ENVIRONMENT) • Aggressive marketing • Irresponsible prescribing • Increased accessibility of illicit opioids • Policy interventions • Prescription drug monitoring programs (PDMPs) • IT integration • Updated ER guidelines • Doctor shopping laws • Good Samaritan laws

18. David Wiss MS RDN All rights reserved BUT WHERE DOES ALL THE PAIN COME FROM? • Psychological? • Emotional pain? • “Self-medication hypothesis”1,2 • Individual susceptibility • “Latent vulnerability” • Childhood maltreatment increases lifetime likelihood of psychiatric disorder3 • Compromised ability to regulate emotions effectively4 1. Danovitch. 2016. “Post-Traumatic Stress Disorder and Opioid Use Disorder: A Narrative Review of Conceptual Models.” Journal of Addictive Diseases 35(3):1–11. 2. Khantzian, Edward. 1987. “The Cocaine Crisis.” 65–74. 3. McCrory, Eamon and Essi Viding. 2015. “The Theory of Latent Vulnerability: Reconceptualizing the Link between Childhood Maltreatment and Psychiatric Disorder.” Development and Psychopathology 27(2):493–505. 4. Puetz, Vanessa and Eamon McCrory. 2015. “Exploring the Relationship Between Childhood Maltreatment and Addiction: A Review of the Neurocognitive Evidence.” Current Addiction Reports 2(4):318–25. “Psychosocial Factors”

19. David Wiss MS RDN All rights reserved McCrory, and Viding. 2015. “The Theory of Latent Vulnerability: Reconceptualizing the Link between Childhood Maltreatment and Psychiatric Disorder.” Development and Psychopathology 27(2):493–505.

20. David Wiss MS RDN All rights reserved SOCIAL VULNERABILITY • Challenges the “brain disease model of addiction” • Considers underlying issues such as anxiety and depression1 • Considers social isolation2 • Consider neighborhood characteristics related to crime and deviance3 • SES, structural racism • Social factors: “under the skin”4 1. Evans, C.J. & Cahill, C.M. 2016. “Neurobiology of Opioid Dependence in Creating Addiction Vulnerability.” 2. Eitan, S, Emery, M.A., Shaw, M.L.S., Bates, and Horrax, C. 2017. “Opioid Addiction: Who Are Your Real Friends?” Neuroscience & Biobehavioral Reviews 83:697–712. 3. Ford, J.A., Sacra, S. and Yohros, A.. 2017. “Neighborhood Characteristics and Prescription Drug Misuse among Adolescents: The Importance of Social Disorganization and Social Capital.” International Journal of Drug Policy 46:47–53. 4. Taylor, S. E., Repetti,R. L. and Seeman, T. 1997. “HEALTH PSYCHOLOGY: What Is an Unhealthy Environment and How Does It Get Under the Skin?” Psychology 48(1):411–47.

21. David Wiss MS RDN All rights reserved WHAT IS TRAUMA? (PSYCHOSOCIAL) • PTSD • Complex Trauma • Stress • Allostatic load • Adverse childhood experiences (ACE) • Dose-dependent increase in risk for drug abuse1,2 • Linked to opioids3 1. Anda, Robert et al. 2002. “Adverse Childhood Experiences, Alcoholic Parents, and Later Risk of Alcoholism and Depression.” Psychiatric Services 53(8):1001–9. 2. Dube, Shanta et al. 2003. “Childhood Abuse, Neglect, and Household Dysfunction and the Risk of Illicit Drug Use: The Adverse Childhood Experiences Study.” Pediatrics 111(3):564–72. 3. Stein, Michael et al. 2017. “Adverse Childhood Experience Effects on Opioid Use Initiation, Injection Drug Use, and Overdose among Persons with Opioid Use Disorder.” Drug and Alcohol Dependence 179:325–29.

22. David Wiss MS RDN All rights reserved BIOLOGICAL CORRELATES OF TRAUMA • Brain regions • Hippocampus • Amygdala • Autonomic nervous system • Vagus nerve • Neurobiochemical measures • Cortisol • Genetics • Epigenetics Marinova, Zoya and Andreas Maercker. 2015. “Biological Correlates of Complex Posttraumatic Stress Disorder—State of Research and Future Directions.” European Journal of Psychotraumatology 6(0):25913.

23. David Wiss MS RDN All rights reserved POST-TRAUMATIC STRESS DISORDER • Increased risk of developing opioid use disorder1 • Opioids distinctly reinforcing • More pronounced in women than men2 • Consistent with self- medication hypothesis • Deficits in reward functioning3 • Increased impulsivity4,5 1. Hassan, Ahmed, Bernard Foll, Sameer Imtiaz, and Jürgen Rehm. 2017. “The Effect of Post-Traumatic Stress Disorder on the Risk of Developing Prescription Opioid Use Disorder: Results from the National Epidemiologic Survey on Alcohol and Related Conditions III.” Drug and Alcohol Dependence 179:260–66. 2. Smith, Smith, Cercone, McKee, and Homish. 2016. “Past Year Non-Medical Opioid Use and Abuse and PTSD Diagnosis: Interactions with Sex and Associations with Symptom Clusters.” Addictive Behaviors 58:167–74. 3. Nawijn, Laura et al. 2015. “Reward Functioning in PTSD: A Systematic Review Exploring the Mechanisms Underlying Anhedonia.” Neuroscience & Biobehavioral Reviews 51:189–204. 4. Black, Anne, Ned Cooney, Carolyn Sartor, Albert Arias, and Marc Rosen. 2018. “Impulsivity Interacts with Momentary PTSD Symptom Worsening to Predict Alcohol Use in Male Veterans.” The American Journal of Drug and Alcohol Abuse 1–8. 5. Weiss, Nicole, Matthew Tull, Jason Lavender, and Kim Gratz. 2013. “Role of Emotion Dysregulation in the Relationship between Childhood Abuse and Probable PTSD in a Sample of Substance Abusers.” Child Abuse & Neglect 37(11):944–54.

24. David Wiss MS RDN All rights reserved Vujanovic, A. A., Wardle, M. C., Smith, L. J., and Berenz, E. C. (2017). Reward functioning in posttraumatic stress and substance use disorders. Current Opinion in Psychology, 14, 49-55.

25. David Wiss MS RDN All rights reserved THE TRAUMA THEORY (PSYCHOSOCIAL FACTORS) • Focused on the individual • Social & environmental factors • Painful life experiences • Altered physiology increases likelihood of opioid addiction • Improving social factors contributing to trauma decrease addiction?

26. David Wiss MS RDN All rights reserved GENETIC VULNERABILITY (BIOLOGICAL FACTORS) • Polymorphisms of dopaminergic genes1 • Increased risk of impulsivity and addiction • Reward Deficiency Syndrome (RDS)2 • DAD2 receptor dysfunction • Heritability of substance- seeking behavior • Genetic Addiction Risk Score (GARS)3 1. Jentsch, David J. et al. 2017. “Dissecting Impulsivity and Its Relationships to Drug Addictions.” Annals of the New York Academy of Sciences 1327(1):1–26. 2. Blum, K. et al. 1996. “The D2 Dopamine Receptor Gene as a Determinant of Reward Deficiency Syndrome.” Journal of the Royal Society of Medicine 89(7):396–400. 3. Blum, Kenneth, Marlene Oscar-Berman, Zsolt Demetrovics, Debmalya Barh, and Mark S. Gold. 2014. “Genetic Addiction Risk Score (GARS): Molecular Neurogenetic Evidence for Predisposition to Reward Deficiency Syndrome (RDS).” Molecular Neurobiology 50(3):765–96.

27. David Wiss MS RDN All rights reserved ADDICTION VULNERABILITY • Genetic vulnerability • Innate predisposition • Psychosocial vulnerability • Environmental factors • Personal factors • Stress • Trauma • ACEs • Interaction effect?1 • Mediators? 1. Egervari, Gabor, Roberto Ciccocioppo, David J. Jentsch, and Yasmin L. Hurd. 2018. “Shaping Vulnerability to Addiction – the Contribution of Behavior, Neural Circuits and Molecular Mechanisms.” Neuroscience & Biobehavioral Reviews 85:117–25.

28. David Wiss MS RDN All rights reserved EPIGENETICS OF DRUG ADMINISTRATION • Mu-opioid receptor (MOR) site1 • Stressful social circumstances predispose individuals to drug abuse2 • Transmittable at multigenerational level (genetics) • Animal models of food addiction3 1. Wei, Li-Na. 2008. “Epigenetic Control of the Expression of Opioid Receptor Genes.” Epigenetics 3(3):119–21. 2. Denhardt, David T. 2018. “Effect of Stress on Human Biology: Epigenetics, Adaptation, Inheritance, and Social Significance.” Journal of Cellular Physiology 233(3):1975–84. 3. Wiss, David A., Kristen Criscitelli, Mark Gold, and Nicole Avena. 2017. “Preclinical Evidence for the Addiction Potential of Highly Palatable Foods: Current Developments Related to Maternal Influence.” Appetite 115:19–27. Nature vs. Nurture

30. David Wiss MS RDN All rights reserved Volkow, N.D., Koob, G. F., and McLellan, T. (2016). Neurobiological advances from the brain disease of addiction. New England Journal of Medicine, 374, 363-371.

31. David Wiss MS RDN All rights reserved DSM-5 SUBSTANCE USE DISORDER (SUD) • Tolerance • Withdrawal • Taking more/longer than intended • Desire/unsuccessful efforts to quit use • Great deal of time taken by activities involved in use • Use despite knowledge of problems associated with use • Important activities given up because of use • Recurrent use resulting in a failure to fulfill important role obligations • Recurrent use resulting in physically hazardous behavior • Continued use despite recurrent social problems associated with use • Craving for the substance MILD: 2-3 items MODERATE: 4-5 items SEVERE: 6+ items

32. David Wiss MS RDN All rights reserved NUTRITION FOR MENTAL HEALTH • History • Vitamin/mineral deficiencies • Essential fatty acids • Amino acids • Trends • “Food and mood” • “Emotional eating” • Here and now • Allergies/sensitivities • Gut health & microbiome • Inflammation & oxidative stress

33. David Wiss MS RDN All rights reserved SUD & EATING DISORDER (ED) • Bidirectional1-4 • Significant overlap • Neurochemically5 • Behaviorally6 • Maladaptive behaviors • Emotion regulation7,8 • Acting rash in distress9 • Coping w/ negative affect10 1. Grilo, C.M., et al., Eating disorders in female inpatients with versus without substance use disorders. Addict Behav, 1995. 20(2): p. 255-260. 2. Gadalla, T. and N. Piran, Eating disorders and substance abuse in Canadian men and women: a national study. Eat Disord, 2007. 15(3): p. 189-203. 3. Root, T.L., et al., Patterns of co-morbidity of eating disorders and substance use in Swedish females. Psychol Med, 2010. 40(1): p. 105-15. 4. Baker, J.H., et al., Eating disorder symptomatology and substance use disorders: prevalence and shared risk in a population based twin sample. Int J Eat Disord, 2010. 43(7): p. 648-58. 5. Hadad, N.A. and L.A. Knackstedt, Addicted to palatable foods: comparing the neurobiology of Bulimia Nervosa to that of drug addiction. Psychopharmacology (Berl), 2014. 231(9): p. 1897-912. 6. Courbasson, C.M., C. Rizea, and N. Weiskopf, Emotional Eating among Individuals with Concurrent Eating and Substance Use Disorders. International Journal of Mental Health and Addiction, 2008. 6(3): p. 378-388. 7. Buckholdt, K.E., et al., Emotion regulation difficultes and maladaptive behaviors: Examination of deliberate self-harm, disordered eating, and substance misuse in two samples. Cognitive Therapy and Research, 2015. 39: p. 140-152. 8. Stewart, S.H., et al., Why do women with alcohol problems binge eat? Exploring connections between binge eating and heavy drinking in women receiving treatment for alcohol problems. J Health Psychol, 2006. 11(3): p. 409-25. 9. Fischer, S., K.G. Anderson, and G.T. Smith, Coping with distress by eating or drinking: role of trait urgency and expectancies. Psychol Addict Behav, 2004. 18(3): p. 269-74. 10. Luce, K.H., P.A. Engler, and J.H. Crowther, Eating disorders and alcohol use: Group differences in consumpion rates and drinking motives. Eating Behaviors, 2007. 8: p. 177-184.

34. David Wiss MS RDN All rights reserved SUD & ED • Comorbidity ranges between 3-50%1-3 • Subclinical ED relatively common • Night eating4,5 • Dietary restraint4 • Body image issues 1. Munn-Chernoff, M.A. and J.H. Baker, A Primer on the Genetics of Comorbid Eating Disorders and Substance Use Disorders. Eur Eat Disord Rev, 2016. 24(2): p. 91-100. 2. Bulik, C.M., M. Slof, and P. Sullivan, Comorbidity of eating disorders and substance-related disorders. Medical Psychiatry, 2004. 27: p. 317-348. 3. Bonfa, F., et al., Treatment dropout in drug-addicted women: Are eating disorders implicated? Eating and Weight Disorders, 2008. 13(2): p. 81-86. 4. Calero-Elvira, A., et al., Meta-analysis on drugs in people with eating disorders. Eur Eat Disord Rev, 2009. 17(4): p. 243-59. 5. Lundgren, J.D., et al., Prevalence of the night eating syndrome in a psychiatric population. Am J Psychiatry, 2006. 163(1): p. 156-8.

35. David Wiss MS RDN All rights reserved SUD – DISORDERED EATING • Women in SUD treatment1 • BED and sub-threshold BED • Bulimia nervosa • Men in SUD treatment2 • First 6 months • Bingeing • Use of food to satisfy drug cravings • 7-36 months • Weight concerns, distress about efforts to lose weight 1. Czarlinksi, J. A., Aase, D. M., & Jason, L. A. (2012). Eating disorders, normative eating self-efficacy and body image self-efficacy: Women in recovery homes. European Eating Disorders Review, 20, 190-195. 2. Cowan, J., & Devine, C. (2008). Food, eating, and weight concerns of men in recovery from substance addiction. Appetite, 50, 33-42.

36. David Wiss MS RDN All rights reserved ALCOHOL & MALNUTRITION • Thiamine deficiency • Wernicke-Korsakoff1 • IV thiamine in hospitals • Vitamin B6 deficiency2 • utilization & formation • Folic acid deficiency3 • B12 & iron inconclusive 1. Martin, P.R., C.K. Singleton, and S. Hiller-Sturmhofel, The role of thiamine deficiency in alcoholic brain disease. Alcohol Research & Health, 2003. 27(2): p. 134-142. 2. Lieber, C.S., Alcohol: Its metabolism and interaction with nutrients. Annual Review of Nutrition, 2000. 20: p. 395-430. 3. Kopczynska, E., et al., [The concentrations of homocysteine, folic acid and vitamin B12 in alcohol dependent male patients]. Psychiatr Pol, 2004. 38(5): p. 947-56. 4. Clugston, R.D. and W.S. Blaner, The adverse effects of alcohol on vitamin A metabolism. Nutrients, 2012. 4(5): p. 356-71. 5. Quintero-Platt, G., et al., Vitamin D, vascular calcification and mortality among alcoholics. Alcohol Alcohol, 2015. 50(1): p. 18-23. • Adverse effects vit A metabolism4 • Low vit D5

37. David Wiss MS RDN All rights reserved ALCOHOL & GUT • EtOH alters microbiome • Dysbiosis in humans1-3 • Increased oxidative stress • Decreased SCFAs • Tight junction disrupted • Bacterial translocation4-8 • Hepatic damage9 1. Mutlu, E.A., et al., Colonic microbiome is altered in alcoholism. Am J Physiol Gastrointest Liver Physiol, 2012. 302(9): p. G966-78. 2. Leclercq, S., et al., Intestinal permeability, gut-bacterial dysbiosis, and behavioral markers of alcohol-dependence severity. Proc Natl Acad Sci U S A, 2014. 111(42): p. E4485-93. 3. Couch, R.D., et al., Alcohol induced alterations to the human fecal VOC metabolome. PLoS One, 2015. 10(3): p. e0119362. 4. Dhanda, A.D. and P.L. Collins, Immune dysfunction in acute alcoholic hepatitis. World J Gastroenterol, 2015. 21(42): p. 11904-13. 5. Chen, P. and B. Schnabl, Host-microbiome interactions in alcoholic liver disease. Gut Liver, 2014. 8(3): p. 237-41. 6. Hartmann, P., C.T. Seebauer, and B. Schnabl, Alcoholic liver disease: the gut microbiome and liver cross talk. Alcohol Clin Exp Res, 2015. 39(5): p. 763-75. 7. Shasthry, S.M. and S.K. Sarin, New treatment options for alcoholic hepatitis. World J Gastroenterol, 2016. 22(15): p. 3892-906. 8. Sung, H., et al., Microbiota-based treatments in alcoholic liver disease. World J Gastroenterol, 2016. 22(29): p. 6673-82. 9. Malaguarnera, G., et al., Gut microbiota in alcoholic liver disease: pathogenetic role and therapeutic perspectives. World J Gastroenterol, 2014. 20(44): p. 16639-48.

39. David Wiss MS RDN All rights reserved NUTRITIONAL TREATMENT FOR ALD • Microbiota-based treatments • Probiotics/prebiotics1 • Fecal transplants? • Polyphenolic compounds2 (EGCG) • RCT: hospitalized pts w/ alcoholic hepatitis got 7 days L. subtilus/S. faecium3 • Sig. restoration of bowel flora 1. Sung, H., et al., Microbiota-based treatments in alcoholic liver disease. World J Gastroenterol, 2016. 22(29): p. 6673-82. 2. Rishi, P., et al., Better Management of Alcohol Liver Disease Using a 'Microstructured Synbox' System Comprising L. plantarum and EGCG. PLoS One, 2017. 12(1): p. e0168459. 3. Han, S.H., et al., Effects of probiotics (cultured Lactobacillus subtilits/ Streptoccocus faecium) in the treatment of alcoholic hepatitis: Randomized-controlled multicenter study. European Journal of Gastroenterology & Hepatology, 2015. 27(11): p. 1300-1306.

40. David Wiss MS RDN All rights reserved GUT LEAKINESS • “Intestinal permeability” • Correlates to depression and alcohol craving1 • At 3 wks. abstinence, those w/ gut leakiness higher:2 • Depression, anxiety, craving • Gut leakiness persists into abstinence3 1. Leclercq, S., et al., Role of intestinal permeability and inflammation in the biological and behavioral control of alcohol-dependent subjects. Brain Behav Immun, 2012. 26(6): p. 911-8. 2. Leclercq, S., et al., Intestinal permeability, gut-bacterial dysbiosis, and behavioral markers of alcohol-dependence severity. Proc Natl Acad Sci U S A, 2014. 111(42): p. E4485-93. 3. Mutlu, E.A., et al., Colonic microbiome is altered in alcoholism. Am J Physiol Gastrointest Liver Physiol, 2012. 302(9): p. G966-78.

43. David Wiss MS RDN All rights reserved Gorky, J. and J. Schwaber, The role of the gut-brain axis in alcohol use disorders. Prog Neuropsychopharmacol Biol Psychiatry, 2016. 65: p. 234-41. NEUROINFLAMMATION

44. David Wiss MS RDN All rights reserved ALCOHOL VS. DRUG ADDICTION • Negative effect of alcohol on nutritional status well-described • Protocols in place (i.e. thiamine, “banana bag”) • Illicit drug-induced malnourishment largely unknown • Primary or secondary? • Poly-drug abuse • Ethical/legal challenges with controlled trial research • Poor patient follow-up most data is speculative, underpowered, retrospective

45. David Wiss MS RDN All rights reserved SUBSTANCE USE DISORDER • SUD growing social/economic burden • New treatment modalities greatly needed • Trends towards “holistic” approaches to recovery including healthful eating • No specialized training programs for nutritionists working with SUD • No established standards of practice

46. David Wiss MS RDN All rights reserved ACADEMY OF NUTRITION AND DIETETICS • Formerly the American Dietetic Association (ADA) • Position paper (1990) supporting need for nutrition intervention in treatment/recovery from addiction • Registered Dietitians (RDs) essential members of the treatment team • Nutrition care integrated into the protocol rather than “patched on” • Nutrition professionals urged to “take aggressive action to ensure involvement in treatment and recovery programs.” American Dietetic Association (1990, September). Position of the American Dietetic Association: Nutrition intervention in treatment and recovery from chemical dependency. Journal of the American Dietetic Association, 90(9), 1274-1277.

47. David Wiss MS RDN All rights reserved CURRENT CLIMATE …Little progress incorporating dietitians into drug rehabilitation programs despite epidemic • Lack of interest from RDNs??? • Associated stigmas of drug abuse • Non-collaboration between public and private sectors • Limited funding for new initiatives • Difficulties conducting research on this population no ins. coverage

48. David Wiss MS RDN All rights reserved OVERVIEW: SUD & NUTRITION • Malnutrition from poor dietary intake1-4 • Large sample of Canadian IV drug users5 • 65% met criteria for hunger • Preference for sweets1,2 • Low intake of fruits and vegetable1,2 1. Baptiste, F., Drugs and diet among women street sex workers and injection drugs user in Quebec City. Candian Journal of Urban Research, 2009. 18(2): p. 78-95. 2. Saeland, M., et al., High sugar consumption and poor nutrient intake among drug addicts in Oslo, Norway. Br J Nutr, 2011. 105(4): p. 618-24. 3. Noble, C. and L. McCombie, Nutritional considerations in intravenous drug misusers: A review of the literature and current issues for dietitians. Journal of Human Nutrition and Dietetics, 1997. 10: p. 181-191. 4. Tang, A.M., et al., Malnutrition in a population of HIV- positive and HIV-negative drug users living in Chennai, South India. Drug Alcohol Depend, 2011. 118(1): p. 73-7. 5. Anema, A., et al., Hunger and associated harms among injection drug users in an urban Canadian setting. Substance Abuse Treatment, Prevention, and Policy, 2010. 5(20).

49. David Wiss MS RDN All rights reserved OVERVIEW: SUD & NUTRITION • Micronutrients low1-4 • Antioxidant deficiencies • Low vitamins E, C, A • Iron deficiency anemia • Inflammatory markers4,5 • Elevated copper & zinc • Oxidant-antioxidant disturbance6,7 • Implicated in relapse8 1. Islam, S.K.N., K.J. Hossain, and M. Ahsan, Serum vitamin E, C and A status of the drug addcits undergoing detoxification: influence of drug habit, sexual practice and lifestyle factors. European Journal of Clinical Nutrition, 2001. 55: p. 1022-1027. 2. Hossain, K.J., et al., Serum antioxidant micromineral (Cu, Zn, Fe) status of drug dependent subjects: Influence of illicit drugs and lifestyle. Subst Abuse Treat Prev Policy, 2007. 2: p. 12. 3. Ross, L.J., et al., Prevalence of malnutrition and nutritional risk factors in patients undergoing alcohol and drug treatment. Nutrition, 2012. 28(7-8): p. 738-43. 4. Mannan, S.J., et al., Investigation of serum trace element, malondialdehyde and immune status in drug abuser patients undergoing detoxification. Biol Trace Elem Res, 2011. 140(3): p. 272-83. 5. Saeland, M., et al., High sugar consumption and poor nutrient intake among drug addicts in Oslo, Norway. Br J Nutr, 2011. 105(4): p. 618-24. 6. Gawad, S.S.A.E., et al., Effects of drug addiction on antioxidant vitamins and nitric oxide levels. J. Basic Appl. Sci. Res., 2010. 1(6): p. 485-491. 7. Zhou, J.F., et al., Heroin abuse and nitric oxide, oxidation, peroxidation, lipoperoxidation. Biomed Environ Sci, 2000. 13(2): p. 131-9. 8. Budzynski, J., et al., Oxidoreductive homeostasis in alcohol-dependent male patients and the risk of alcohol drinking relapse in a 6-month follow-up. Alcohol, 2016. 50: p. 57-64.

50. David Wiss MS RDN All rights reserved POLY-SUBSTANCE ABUSE • Added sugar 30% intake of drug addicts in Norway (n=220)1 • Sugar & sugar- sweetened foods preferred > 60% of respondents 1. Saeland, M., Haugen, M., Eriksen, F. L., Wandel, M., Smehaugen, A., Bohmer, T., & Oshaug, A. (2011). High sugar consumption and poor nutrient intake among drug addicts in Oslo, Norway. British Journal of Nutrition, 105, 618-624.

51. David Wiss MS RDN All rights reserved COCAINE & NUTRITION • Low PUFA levels 2 weeks after hospital admission • Predictor of relapse1 PUFAs neurotransmission2 • Serotonin & dopamine • 3g omega-3 PUFAs daily for 3 months decreased anxiety3 • Effect persisted 3 months later 1. Buydens-Branchey, L., et al., Polyunsaturated fatty acid status and relapse vulnerability in cocaine addicts. Psychiatry Res, 2003. 120(1): p. 29-35. 2. Hibbeln, J.R., et al., Essential fatty acids predict metabolites of serotonin and dopamine in cerebrospinal fluid among healthy control subjects, and early- and late-onset alcoholics. Biological Psychiatry, 1998. 44(4): p. 235-242. 3. Buydens-Branchey, L. and M. Branchey, n-3 polyunsaturated fatty acids decrease anxiety feelings in a population of substance abusers. J Clin Psychopharmacol, 2006. 26(6): p. 661-5.

52. David Wiss MS RDN All rights reserved COCAINE & GUT • Sample of HIV patients1 • Higher relative abundance of Bacteriodetes in their intestines • Next up: targeting the microbiome-gut-brain-axis in the treatment of CUD?2 1. Volpe, G.E., et al., Associations of Cocaine Use and HIV Infection With the Intestinal Microbiota, Microbial Translocation, and Inflammation. Journal of Studies on Alcohol and Drugs, 2014. 75(2): p. 347-357. 2. Harrod, S.B., et al., The microbiota-gut-brain axis as a potential therapeutic approach for HIV-1+ cocaine abuse. Drug & Alcohol Dependence, 2015. 156: p. e90-e91.

54. David Wiss MS RDN All rights reserved METH & NUTRITION • Associated w/ BMI1 • Animal models • appetite hormone NP-Y2,3 • Hyperphagia and rebound weight gain during abstinence4 • Associated w/ bulimia nervosa5 and efforts to control weight6 • Speed users nearly 2x as likely to become obese vs. opioid users7 1. Lv, D., et al., The Body Mass Index, Blood Pressure, and Fasting Blood Glucose in Patients With Methamphetamine Dependence. Medicine (Baltimore), 2016. 95(12): p. e3152. 2. Kobeissy, F.H., et al., Changes in leptin, ghrelin, growth hormone and neuropeptide-Y after an acute model of MDMA and methamphetamine exposure in rats. Addict Biol, 2008. 13(1): p. 15-25. 3. Goncalves, J., et al., Effects of drugs of abuse on the central neuropeptide Y system. Addict Biol, 2016. 21(4): p. 755-65. 4. Orsini, C.A., et al., Food consumption and weight gain after cessation of chronic amphetamine administration. Appetite, 2014. 78: p. 76-80. 5. Glasner-Edwards, S., et al., Bulimia nervosa among methamphetamine dependent adults: association with outcomes three years after treatment. Eat Disord, 2011. 19(3): p. 259-69. 6. Neale, A., S. Abraham, and J. Russell, "Ice" use and eating disorders: a report of three cases. Int J Eat Disord, 2009. 42(2): p. 188-91. 7. McIlwraith, F., et al., Is low BMI associated with specific drug use among injecting drug users? Subst Use Misuse, 2014. 49(4): p. 374-82.

55. David Wiss MS RDN All rights reserved METH & GUT • Animal models • Disruption of epithelial barrier integrity & function1 • General dysbiosis2 • Phascolarcobacterium repressed • Produces proprionate (SCFA) • Ruminococcaceae elevated • Linked to anxiety • Must reduce oxidative stress! • Meth-induced neurotoxicity • Improved by selenium3 • Improved by CoQ104 1. Bennet, B.L., J. Ma, and S. Roy. Effect of methamphetamine on the gut epithelial barrier function. in Showcase of Undergraduate Research and Creative Endeavors. 2016. Winthrop University. 2. Ning, T., et al., Gut microbiota analysis in rats with methamphetamine-induced conditioned place preference. bioRxiv, 2017. 3. Imam, S.Z. and S.F. Ali, Selenium, an antioxidant, attenuates methamphetamine-induced dopaminergic toxicity and peroxynitrite generation. Brain Res, 2000. 855(1): p. 186-91. 4. Klongpanichapak, S., et al., Attenuation of cocaine and methamphetamine neurotoxicity by coenzyme Q10. Neurochem Res, 2006. 31(3): p. 303-11.

57. David Wiss MS RDN All rights reserved OPIOIDS • Users prefer quick, cheap, convenient, sweet foods1 • Low fiber • Easily digestible • Calorically dense ice cream • Fruit & vegetable consumption generally low 1. Neale, J., Nettleton, S., Pickering, L., & Fischer, J. (2012). Eating patterns among heroin users: a qualitative study with implications for nutritional interventions. Addiction, 107, 635-641.

58. David Wiss MS RDN All rights reserved Nakah, A. E., Frank, O., Louria, D. B., Quinones, M. A., Baker, H. (1979). A vitamin profile of heroin addiction. American Journal of Public Health, 69(10), 1058-1060. • Classic heroin study • n = 149 • 45% deficient in vitamin B6 • Replicated in 19811 • 37% deficient in folate • Replicated in 20042 • 19% deficient in thiamine • Elevated Mg and Phos in methadone patients2 1.Heathcote, J., & Taylor, K. B. (1981). Immunity and nutrition in heroin addicts. Drug and alcohol dependence, 8, 245-255 2. Estevez, J. F. D., Estevez, F. D., Calzadilla, C. H., Rodriquez, E. M. R., Romero, C. D., & Serra-Majem, L. (2004). Application of linear discriminant analysis to the biochemical and haematological differentiation of opiate addicts from healthy subjects: A case-control study. European Journal of Clinical Nutrition, 58, 449-455.

59. David Wiss MS RDN All rights reserved OPIOIDS & GUT • Delayed gastric emptying1 • Constipation-related symptoms2 • Straining • Hard stools • Painful/infrequent/incomplete BM • Opioid-induced bowel dysfunction2 • Dry mouth, heartburn • Nausea, vomiting • Abdominal pain, bloating 1. Nimmo, W.S., et al., Inhibition of gastric emptying and drug absorption by narcotic analgesics. Br J Clin Pharmacol, 1975. 2(6): p. 509-13. 2. Leppert, W., Emerging therapies for patients with symptoms of opioid-induced bowel dysfunction. Drug Des Devel Ther, 2015. 9: p. 2215-31.

60. David Wiss MS RDN All rights reserved OPIOIDS & GUT • Motionless environment favorable to bacterial growth?1 • Delayed GI transmit time increased intraluminal concentrations of toxins?1 • Animal models • Disrupted intestinal epithelium2 • Bacterial translocation3 • Inflammation in small intestine3 • E. faecalis 100x (vs. placebo)4 1. Mora, A.L., et al., Moderate to high use of opioid analgesics are associated with an increased risk of Clostridium difficile infection. Am J Med Sci, 2012. 343(4): p. 277-80. 2. Babrowski, T., et al., Pseudomonas aeruginosa virulence expression is directly activated by morphine and is capable of causing lethal gut-derived sepsis in mice during chronic morphine administration. Ann Surg, 2012. 255(2): p. 386-93. 3. Meng, J., et al., Morphine induces bacterial translocation in mice by compromising intestinal barrier function in a TLR-dependent manner. PLoS One, 2013. 8(1): p. e54040. 4. Wang, F., Temporal modulation of gut microbiome and metabolome by morphine. 2015.

61. David Wiss MS RDN All rights reserved OPIOIDS & EATING BEHAVIOR • High sweet consumption1-3 • Low intake of dietary fiber1-3 • Minimal digestive efforts (eating candy makes sense…) • Some attempt to manage and improve their health while using daily4 1. Morabia, A., et al., Diet and opiate addiction: A quantitative assessment of the diet of non- institutionalized opiate addicts. British Journal of Addiction, 1989. 84: p. 173-180. 2. Zador, D., P.M. Lyons Wall, and I. Webster, High sugar intake in a group of women on methadone maintenance in South Western Sydney, Australia. Addiction, 1996. 91(7): p. 1053-1061. 3. Alves, D., et al., Housing and employment situation, body mass index and dietary habits of heroin addicts in methadone maintenance treatment. Heroin Addict Relat Clin Probl, 2011. 13(1): p. 11-14. 4. Drumm, R.D., et al., “I’m a health nut!” Street drug users’ accounts of self-care strategies. Journal of Drug Issues, 2005. 35(3): p. 607-630.

62. David Wiss MS RDN All rights reserved WHAT HAPPENS DURING SUD RECOVERY? • Weight gain in early recovery1-4 • Hyperphagia after abstinence5 • Dysfunctional eating behaviors • Sample of men (n=25)2 • Bingeing, using food to regulate mood • Women (n=124) concerned weight gain will trigger relapse6 • Weight-related concerns in 70% women (n=297)7 • It gets tricky… 1. Hodgkins, C., K. Frost-Pineda, and M.S. Gold, Weight gain during substance abuse treatment: the dual problem of addiction and overeating in an adolescent population. J Addict Dis, 2007. 26 Suppl 1: p. 41-50. 2. Cowan, J.A. and C.M. Devine, Food, eating, and weight concerns of men in recovery from substance addiction. Appetite, 2008. 50(1): p. 33-42. 3. Emerson, M., et al., Unhealthy Weight Gain During Treatment for Alcohol and Drug Use in Four Residential Programs for Latina and African American Women. Substance Use & Misuse, 2009. 44(11): p. 1553-1565. 4. Krahn, D., et al., Sweet intake, sweet-liking, urges to eat, and weight change: relationship to alcohol dependence and abstinence. Addict Behav, 2006. 31(4): p. 622-31. 5. Edge, P.J. and M.S. Gold, Drug withdrawal and hyperphagia: lessons from tobacco and other drugs. Curr Pharm Des, 2011. 17(12): p. 1173-9. 6. Lindsay, A.R., et al., A gender-specific approach to improving substance abuse treatment for women: The Healthy Steps to Freedom program. J Subst Abuse Treat, 2012. 43(1): p. 61-9. 7. Warren, C.S., et al., 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): p. 494-501.

63. David Wiss MS RDN All rights reserved Warren, C. S., Lindsay, A. R., White, E. K., Claudat, K., & Velasquez, S. C. (2013). Weight- related concerns related to drug use for women in substance abuse treatment: Prevalence and relationships with eating pathology. Journal of Substance Abuse Treatment, 44, 494- 501. “If weight-related concerns motivate substance use and this concern is not addressed in traditional substance abuse programs, treatment will likely be less effective because a core etiological factor motivating substance abuse would remain unaddressed.”

64. David Wiss MS RDN All rights reserved “SOCIAL DRUGS” CAFFEINE & NICOTINE • Used for synergistic effects • Caffeine as cue for nicotine • Some treatment centers do not allow “social drugs,” others allow without any formal regulation • Often used as a breakfast substitute, and may have adverse effects in the afternoon1 1. Dekker, T. (2000). Nutrition and recovery. Toronto, CAN: Centre for Addiction and Mental Health.

65. David Wiss MS RDN All rights reserved CAFFEINE • No longer just coffee, tea, chocolate and sodas • Energy drinks, pills • Workout supplements (>300mg) • “Caffeinism” 600-750 mg/day • >1000 mg/day defined as toxic1 • DSM-5: >250 mg can be intoxicating • Affects duration/quality of sleep 1. Hilton, T. (2007). Pharmacological issues in the management of people with mental illness and problems with alcohol and illicit drug misuse. Criminal Behavior and Mental Health, 17, 215-224.

66. David Wiss MS RDN All rights reserved NICOTINE • Increases metabolism1 • Acts as appetite suppressant1 • Compromises senses of taste and smell2 • Smokers have tendency to choose hyperpalatable snack foods • Less likely to enjoy the taste of fruits and vegetables • Smokers lower in plasma vitamin C and total carotenoids, independent of dietary intake3 Introducing the vape? 1. Novak, C. M., & Gavini, C. K. (2012). Smokeless weight loss. Diabetes, 61, 776-777. 2. Hatcher, A. S. (2008). Nutrition and addictions. Dallas, TX: Understanding Nutrition, PC. 3. Dekker, T. (2000). Nutrition and recovery. Toronto, CAN: Centre for Addiction and Mental Health.

67. David Wiss MS RDN All rights reserved Morean, M. E., Wedel, A. V. (2017). Vaping to lose weight: Predictors of adult e-cigarette use for weight loss or control. Addictive Behaviors, 66, 55-59. • n = 459 e-cig users • Online survey • 13.5 % reported vaping for weight loss/control • Of those, more likely: • Vape frequently • Be overweight • Restrict calories • Have poor impulse control • Prefer coffee/vanilla flavors

68. David Wiss MS RDN All rights reserved HORMONES • Neuronal & gut hormones • “Cross-talk” via “Gut-brain axis” • Gut peptides released from enteroendocrine cells in response to pre-absorptive nutrients can reach brain1 • Indirectly • Receptors in enteric nervous system • Directly • Systemic circulation or lymphatics 1. Bauer, P. V., Hamr, S. C., & Duca, F. A. (2015). Regulation of energy balance by a gut-brain axis and involvement of the gut microbiota. Cellular and Molecular Life Sciences. doi:10.1007/s00018- 015-2083-z

70. David Wiss MS RDN All rights reserved BIG PICTURE – GOALS • Not typically weight-focused • Relapse prevention • Disease prevention • Focus on overall health • Body, mind, spirit • Behavior change & self-efficacy • “Sanity restoration” • “Recovery” • Can be difficult to measure Eventually developing a relationship w/ food & exercise that is intuitive/personal • Avoid “quick fix” whenever possible

71. David Wiss MS RDN All rights reserved INTERVENTIONS – “INTUITIVE EATING” Can we trust our body wisdom? • Near gut homeostasis • Low addictive symptomatology • Hormonal milieu relatively stable • Mindfulness training YES – in sync with intuition • Gut dysbiosis • Addiction/withdrawal/craving • Hormonal extremes • Mindless eating NO – addiction running the show Guarner et al. (2003)

72. David Wiss MS RDN All rights reserved GOOD VS. BAD FOODS? • As an eating disorder specialist, this simplistic distinction can cause more harm than good • Cognitive distortion • HOWEVER, we can start to discern between: • Real food vs. processed food • Non-addictive vs. addictive food • Gut healing vs. gut harming • If it has the potential to promote dysbiosis, think twice! “Everyone knows how important the brain is. We have all sorts of educational protocols in place for the brain. But what about the second brain? If the gut truly is the second brain, we need educational protocols for the gut.” David Wiss MS RDN Nutrition in Recovery

73. David Wiss MS RDN All rights reserved TREATMENT-BASED EVIDENCE • Most people report that eating less “processed foods” & more “whole foods” improves wellness & mood • Impact more pronounced in some • But we never really knew WHY... UNTIL NOW? • Many highly processed foods have ingredients (e.g. emulsifiers) that negatively impact gut microbiota!

74. David Wiss MS RDN All rights reserved ADDICTION-LIKE EATING • Over-activation of reward pathways • Subsequent compulsive-like behavior1 • Dysfunction of prefrontal cortex2 • Weighs pros/cons (executive function) • Unlimited access to highly palatable foods in SUD treatment? • Does the food served in SUD treatment lead to impulsive eating?3 1. Garcia-Garcia, I., et al., Reward processing in obesity, substance addiction and non-substance addiction. Obes Rev, 2014. 15(11): p. 853-69. 2. Goldstein, R.Z. and N.D. Volkow, Dysfunction of the prefrontal cortex in addiction: neuroimaging findings and clinical implications. Nat Rev Neurosci, 2011. 12(11): p. 652-69. 3. Dawe, S. and N.J. Loxton, The role of impulsivity in the development of substance use and eating disorders. Neuroscience and Behavioral Reviews, 2004. 28: p. 343-351.

76. David Wiss MS RDN All rights reserved NUTRITION EDUCATION TOPICS Sugar, Salt, Fat Food Group Systems Eating for Mental Health Inflammation and Anti-Inflammatory Foods Emotional Eating Cravings and Appetite Control Gut Microbiome The Importance of Fiber Caffeine and Nicotine Fads and Myths Body Image and Disordered Eating Exercise in Recovery Budgeting and Shopping Mindful Eating Cooking in Recovery Hands-on Nutrition

78. David Wiss MS RDN All rights reserved SUD NUTRITION INTERVENTIONS • Positive association between nutrition edu. & SUD outcomes: • VA system1 • Prison system2 • Residential facilities3,4 • Women with body image issues5 • Cooking classes (Los Angeles)6 1. Grant, L.P., B. Haughton, and D.S. Sachan, Nutrition education is positively associated with substance abuse treatment program outcomes. J Am Diet Assoc, 2004. 104(4): p. 604-10. 2. Curd, P., K. Ohlmann, and H. Bush, Effectiveness of a voluntary nutrition education workshop in a state prison. J Correct Health Care, 2013. 19(2): p. 144-50. 3. Barbadoro, P., et al., The effects of educational intervention on nutritional behaviour in alcohol-dependent patients. Alcohol and Alcoholism, 2011. 46(1): p. 77-9. 4. Cowan, J.A. and C.M. Devine, Process evaluation of an environmental and educational nutrition intervention in residential drug- treatment facilities. Public Health Nutr, 2012. 15(7): p. 1159-67. 5. Lindsay, A.R., et al., A gender-specific approach to improving substance abuse treatment for women: The Healthy Steps to Freedom program. J Subst Abuse Treat, 2012. 43(1): p. 61-9. 6. Moore, K., et al., Hands-on Nutrition and Culinary Intervention within a Substance Use Disorder Residential Treatment Facility. Journal of the Academy of Nutrition and Dietetics, 2016. 116(9): p. A20.

79. David Wiss MS RDN All rights reserved MEDICATION How do medications impact gut? “Better collaboration among treatment professionals is needed in order to serve the multifaceted needs of chemical dependent patients, and reduce prescriptive care contraindicated in the condition of substance abuse”1 1. Kaiser, S.K., K. Prendergast, and T.J. Ruter, Nutritional Links to Substance Abuse Recovery. Journal of Addictions Nursing, 2008. 19(3): p. 125-129.

80. David Wiss MS RDN All rights reserved Le Bastard, Q., Al-Ghalith, G. A., Gregoire, M., Chapelet, G., Javaudin, F., Dailly, E., Batard, E., Knights, D., & Montassier, E. (2017). Systematic review: human gut dysbiosis induced by non- antibiotic prescription medications. Alimentary Pharmacology & Therapeutics. doi:10.1111/apt.14451

83. David Wiss MS RDN All rights reserved GUT-BRAIN AXIS IN SUD • Must consider: • Vagus nerve • Production of neurotransmitters in the gut • Hyptholamic-pituitary adrenal (HPA) axis • Next up: “psychobiotic” treatments targeting the “ecology within”1 • New avenues for treating anxiety and depression?2 1. Skosnik, P.D. and J.A. Cortes-Briones, Targeting the ecology within: The role of the gut-brain axis and human microbiota in drug addiction. Med Hypotheses, 2016. 93: p. 77-80. 2. Rieder, R., et al., Microbes and mental health: A review. Brain Behav Immun, 2017.

84. David Wiss MS RDN All rights reserved Skosnik, P. D., Cortes-Briones, J. A. (2016). Targeting the ecology within: The role of the gut-brain axis and human microbiota in drug addiction. Medical Hypotheses, 93, 77-80. • Potential links between microbiota and drug addiction: • Stress • HPA axis • Depression • Serotonin production in the gut • Dopamine

85. David Wiss MS RDN All rights reserved TREATMENT IMPLICATIONS? • Differential treatments for different severity? • Must consider trauma history • Sensorimotor psychotherapy • EMDR? • Should consider neuroscience • Pharmaceutical • Nutraceutical • Nutritional • Spiritual approaches? • Bio-Psycho-Social-Spiritual

86. David Wiss MS RDN All rights reserved NUTRITION INTERVENTIONS • “Western Diet” – PROBLEM • Low in fiber • High in sugar and/or artificial sweet • High in inflammatory fats • Omega-6 and certain saturated fats • Nutrition in Recovery – SOLUTION • High in fiber • Low in sugar, no artificial sweeteners • High in anti-inflammatory omega-3s • Lower in pro-inflammatory omega-6 Priority #1 Transitions are typically gradual & progressive. Gut will hardly allow for anything else!

87. David Wiss MS RDN All rights reserved OPERATION: HEAL THE GUT! Gut-Brain Communication1 Brain-Gut (Bi-Directional) “Psychological treatments are known to improve functional gastrointestinal disorders, the next wave of research may involve preventative microbiological gut based treatments for primary psychological presentations…” 1. Keightley, P. C., Koloski, N. A., & Talley, N. J. (2015). Pathways in gut- brain communication: Evidence for distinct gut-to-brain and brain-to- gut syndromes. Australian & New Zealand Journal of Psychiatry, 49(3), 207-214.

88. David Wiss MS RDN All rights reserved THE IMPORTANCE OF FIBER • Gradual/progressive reintroduction • Low fiber tolerance creates significant barriers for nutrition therapy involving fruits, vegetables, whole grains, beans • Increase 2-4 g/week to meet recs: • 38 g/day men, 25 g/day women • Ages 14-50 Focus on improved gut health • Nutrition for mental health is the future! #NutritionalPsychiatry

89. David Wiss MS RDN All rights reserved INTERVENTIONS – FIBER • Get fiber from food, not from fiber supplements! • Fruits • Vegetables – emphasize raw • Whole grains • Beans • Nuts/seeds – emphasize raw • Eat a wide range of plant foods on a daily basis • F or V with every meal/snack Every time you eat: Fiber Fat Protein

91. David Wiss MS RDN All rights reserved ED NUTRITION THERAPY 101 • Avoid any dietary extremes • Intermittent fasting • Ketogenic • Vegan? (controversial) • Nudge toward vegetarian? • Regular feeding patterns • 3 meals, 3 snacks • 3 meals, 2 snacks • 3 meals, 1 snack • 3 meals • Meals/snacks are BALANCED Blind weights? Important data? Group meals Accountability Culture of Recovery Starts w/ staff 

92. David Wiss MS RDN All rights reserved ED BEHAVIORS TO WATCH FOR • Bingeing • Skipping meals • Dieting behavior • Lots of “charge” around food • Leaving right after eating • Enforce 30 minute “watch” • Laxatives/teas • Weight loss supplements • Hiding food, playing with food • Talking about food and/or body • Social media following Exercise Addiction Contraband list? + accountability

93. David Wiss MS RDN All rights reserved NUTRITIONAL TREATMENT • Must consider biology: • A calorie is NOT a calorie • It is often “about the food” • Food industry continues to deny responsibility, always stressing individual responsibility for eating, and pointing to lack of exercise • Psychological interventions alone are not sufficient • Educational efforts alone are not sufficient we need an

94. David Wiss MS RDN All rights reserved NUTRITION INTERVENTIONS – GOALS • Immediately bombarding with pills and supplements upon entering treatment may fail to support behavioral aspects of recovery • If individuals begin using again, efforts to correct nutritional deficiencies are futile, and are likely to redevelop! behavioral intervention

95. David Wiss MS RDN All rights reserved BIG PICTURE – GOALS • Cooking Classes • Should be a mandatory part of treatment! • Life Skills • Grocery shopping • Food safety • Meal planning • Kitchen cleaning

97. David Wiss MS RDN All rights reserved TABLE 2: Overall Recommendation for Recovery from all Substance Use Disorders  2-3 L of water per day, replacing sweetened beverages  Emphasis on plant proteins from beans, nuts, seeds  Emphasis on whole grains (oats, farro, quinoa, barley, etc.) over refined grains  “Anti-inflammatory diet” rich in antioxidant vitamins A, C, E, selenium, iron, omega-3  Sources of vitamin A: carrots, pumpkin, sweet potatoes, spinach  Sources of vitamin C: bell peppers, kiwi, broccoli, strawberries  Sources of vitamin E: almonds, sunflower seeds, avocado, peanut butter  Sources of selenium: brazil nuts, yellowfin tuna, turkey, halibut  Sources of iron: red meat, lentils, pumpkin seeds, kidney beans  Sources of omega-3: fatty fish, chia seeds, flax seeds, walnuts  Gradual increase in fiber intake to meet daily recommendations: 25 g/day women, 38 g/day men  Get fiber from whole food over dietary supplements  Sources of fiber: beans, whole grains, berries, cruciferous vegetables  For additional fiber, use chia seeds soaked in water  Eat breakfast within 30 minutes of waking up  Eat smaller meals every 2.5-4.5 hours (5-6 times/day)  Fruit or vegetable with every meal/snack  Raw vegetable daily  Fermented foods (not fermented beverages!)  Max 400 mg caffeine/day (3-4 cups of coffee)  Use green tea over coffee when possible  Minimize artificial sweeteners

98. David Wiss MS RDN All rights reserved OPIOIDS – RECS TABLE 4: Recommendations for Recovery from Opioids  Protein-rich diet: 1.2-2.0 g/kg/day (whey or plant-based protein powder can help)  Use fruit (fresh/frozen/dried) for “sweet tooth”  Gradual weight gain if underweight (instead of rapid, ideally under 10 lbs./month)  Full spectrum multivitamin/mineral broken into at least two daily separate doses  Additional vitamin D3 if deficient (also direct sunlight for 20 min twice/week)  Omega-3 DHA-rich 3g/day, reduced exposure to omega-6 fatty acids  Probiotic supplement (refrigerated) Where More Information is Needed:  If liquid multivitamin/mineral supplements work better for absorption of micronutrients  If supplemental vitamin B6 is beneficial for opioid users, and optimal dosage  Which particular strains of probiotic bacteria are optimal for opioid users  How to best manage opioid-induced bowel dysfunction nutritionally  If digestive enzymes are effective, and optimal dosage  If supplements containing precursors for neurotransmitters are effective, and optimal dosage  Link between opioids, cholesterol, and hormones  Effectiveness of “sunlight therapy” in recovery from opioid addiction  Nutritional implications of Suboxone (buprenorphine/naloxone) and Vivitrol (naltrexone)

99. David Wiss MS RDN All rights reserved MORE INFO NEEDED TABLE 5: Overall Where More Information is Needed  Optimal rate to increase fiber intake for to improve fiber tolerance  If antioxidant supplements such as turmeric/curcumin, coenzyme Q10, alpha lipoic acid, resveratrol, and flavonoid polyphenols are beneficial, and optimal dosage  If supplements for “leaky gut” used by functional medicine practitioners are effective, and optimal dosage  If supplements for “immune support” are effective, and optimal dosage  Which probiotic strains are best for AUD/SUD, and optimal dosage  If stool samples will soon be able to inform nutrition intervention strategies  The role of magnesium in recovery from AUD/SUD  How genetic testing can inform nutrition intervention strategies  If high-dose amino acid therapies are effective, and optimal dosage  How to best treat co-occurring AUD/SUD and ED  How to determine necessity for referring to ED treatment  How to best treat co-occurring AUD/SUD and FA  Best ways to address body image concerns in AUD/SUD treatment  Best strategies to reduce nighttime eating in treatment settings  How “mindful eating” can benefit individuals with AUD/SUD  If long-term nutrition therapy with consistent eating patterns can impact hormones sufficient to normalize reward processing in the brain  Long-term nutritional implications of medications, and how to best counsel patients on it  Best topics for group education in treatment settings  Best practices for implementation of cooking classes and other “life skills” workshops  Best practices for implementation of nutrition guidelines in treatment settings  How smoking/vaping impacts taste preferences and relationship to food  Best strategies to encourage reduction/cessation of caffeine/nicotine  Best strategies for incorporating exercise into treatment settings  Best ways to collect data and publish findings LEGEND: AUD (alcohol use disorder); SUD (substance use disorder); ED (eating disorder); FA (food addiction)

100. David Wiss MS RDN All rights reserved WHAT CAN THE RDN DO AS A MEMBER OF THE TREATMENT TEAM? Every patient who walks into SUD treatment should be assessed by a behavioral health dietitian! • Screen for ED and other dysfunctional/disordered food behaviors • Request nutrition-related labs for high-risk patients • Run groups and offer individual counseling (Nutrition Therapy) • Collect data and publish findings (that means YOU!) • Develop educational curriculum, life skills experiential therapies • Plan special events ex: Supermarket Tours • Attend treatment planning and staff meetings • Work w/ doctors/therapists/counselors to help achieve treatment goals • Nutrition/exercise interventions to facilitate behavior change favorable to long- term recovery and improved quality of life • Audit the menu and suggest substitutions within the budget • Food service and food safety improvements • Work with the chef to improve the “food environment”

105. David Wiss MS RDN All rights reserved WHAT IS YOUR FOOD PHILOSOPHY? “All foods fit. But not all foods fit for all people. And just because the food industry manufactures and sells it, does not mean we have to include it.”

107. David Wiss MS RDN All rights reserved Practice Applications 1) The opioid problem is multi-factorial and multi-causal. To end the crisis we need effective multidisciplinary collaboration. 2) Nutrition can be a part of the recovery process, and should emphasize gastrointestinal health, while minimizing the potential for disordered eating. 3) Registered dietitian nutritionists are positioned to be a part of an SUD treatment team, and can use the guidelines presented herein.