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This post is co-authored by Khary Rigg, Ph.D., and Melody Chavez, RDN/LDN, MPH.
The large number of Americans who misuse opioids remains a major public health concern. Recent data show that over 13 million Americans report past-year misuse, and well over 2 million meet the clinical criteria for opioid use disorder (OUD). Not surprisingly, the amount of people seeking treatment for OUD has also increased. A concern, however, is that drug treatment providers give little thought to the ways that OUD can influence their clients' nutrition, weight, and eating habits.
Unknown to many addiction providers is that OUDs can cause metabolic changes, constipation, and weight loss. OUD can also lead to a lifestyle that results in inadequate food intake and unhealthy eating patterns. The nutritional dimensions of OUD treatment are particularly relevant for certain subgroups of clients that might require specialized diets, such as pregnant women and persons with diabetes.
Nutritional factors associated with OUD can also hinder treatment outcomes. As we aim to improve clinical outcomes for clients with OUD, providers could benefit from learning more about the nutritional consequences of the disorder and the important role nutrition can play in promoting recovery. Here are four ways that OUD and nutrition are connected:
OUD and Malnutrition
As OUDs become more severe, and a focus on eating a balanced diet is replaced with misusing opioids, malnutrition can occur. It is not uncommon for individuals with OUD to experience housing instability, have dysfunctional family relationships, and experience criminal justice involvement, all of which can make eating healthy more challenging. Clients whose lifestyles center around misusing opioids can start infrequently eating, due to their diminished interest in food, appetite suppression from increased levels of dopamine, and other competing priorities. Eating habits that have been documented among persons with OUD include eating less than two meals a day, fasting to boost or prolong their opioid high, skipping meals, and consuming few fruits and vegetables.
OUD and Food Insecurity
It is estimated that food insecurity, the inability to obtain adequate healthy food on a day-to-day basis, ranges from 30 to 70 percent among people who use opioids intravenously. In fact, some of the communities hardest hit by the overdose epidemic are among the poorest in the country. Many of these economically depressed neighborhoods being impacted by the epidemic are in food deserts that have limited access to affordable, nutritious food.
Making matters worse is that these communities are often oversaturated with unhealthy dining options, such as fast-food restaurants. Clients with OUD from these neighborhoods also tend to be challenged with a lack of adequate housing and unemployment, which further exacerbates food insecurity issues, making healthy eating a real challenge.
OUD and Co-Occurring Infectious Diseases
Rates of the human immunodeficiency virus (HIV) and hepatitis C (HCV) are elevated among people with OUD. Some of these co-occurring conditions can significantly affect an individual's nutritional status. For example, a high percentage of HCV will go undiagnosed, damaging the liver and ultimately leading to liver disease, which may include cirrhosis and hepatocellular carcinoma. As the liver's primary role is controlling carbohydrates, protein, fat, and energy metabolism, an individual with progressive liver disease may develop early satiety, loss of appetite, nausea, delayed gastric emptying, and impaired absorption leading to malnutrition.
OUD clients living with HIV are also at risk for nutritional problems. Decreased dietary intake due to malabsorption related to HIV-mucosal changes and gastrointestinal problems are a possibility. Antiretroviral medications used to treat HIV can also affect metabolism, as well as increase lean body mass breakdown, leading to unwanted weight loss.
Nutrition and OUD Medications
Medications used to treat OUD can have an effect on clients' weight and nutritional status. Methadone maintenance, for example, can cause hormonal abnormalities that result in weight gain and glycemic dysregulation. There is also evidence that people may gain weight on methadone because of an increased preference for sweet-tasting foods while being maintained on the medication.
Naltrexone and buprenorphine, which are also used to treat OUD, have not been well studied with regards to their nutritional implications for clients with OUD. However, nutritionally relevant side effects include constipation, nausea, vomiting, dry mouth, abdominal pain, low potassium levels, and magnesium deficiency.
What OUD Treatment Providers Can Do
One suggestion for treatment programs is that nutrition screenings and assessments be integrated into OUD treatment. Nutrition screenings allow for the identification of a client who is at risk for malnutrition. Following the recognition of a nutritionally compromised client, a nutritional assessment could be conducted to determine the presence of any co-occurring nutrition disorders. The early use of validated nutrition instruments, such as the MUST (Malnutrition Universal Screening Tool) and the MNA-SF (Mini Nutritional Assessment-Short Form), can help identify and resolve dietary issues that hinder OUD treatment outcomes. In addition, screening for food insecurity can assist providers in tailoring interventions for clients living in food deserts.
Efforts to minimize withdrawal symptoms during detoxification rarely include nutritional interventions, but an essential part of the detoxification process is eating and hydration to replace lost nutrients. Consuming plenty of water and drinks that contain electrolytes (e.g., coconut water), as well as eating foods high in calcium (e.g., yogurt), magnesium (e.g., almonds), and potassium (e.g., banana) can help the body recover during detoxification.
As clients begin the recovery process, this new chapter in their lives can create anxiety and depression. Macro and micronutrient deficiencies can create a breeding ground for these symptoms to flourish, which can trigger a relapse. Macronutrients, such as carbohydrates, protein, essential fatty acids, and vitamins and minerals, are the first step in facilitating the normalization of neurotransmitters and mood during recovery. Micronutrients, such as folate and vitamins B6 and B12, help the body synthesize tryptophan to serotonin, which can make clients feel emotionally stable and less anxious.
It is particularly important to assess clients' nutritional intake while on OUD medications. It is recommended for clients being treated with methadone to consume adequate fiber (e.g., fruit) and water to help alleviate side effects. Also, alcohol and grapefruit juice should be avoided as it could require dose adjustment to avoid drug toxicity. With extended-release formulations of buprenorphine (Probuphine and Sublocade) and naltrexone (Vivitrol) now being available and prescribing rates on the rise, additional research on how these medications impact weight and eating habits is needed.
Clearly, having an OUD can have numerous nutritional implications. Some of these are due to physical or metabolic changes, while others stem from clients' life circumstances and co-occurring health conditions. Drug treatment providers should keep in mind that a poor diet can compromise clients' immune systems, increase the risk of chronic diseases (e.g., diabetes, heart disease), and contribute to lethargy. Addiction professionals would also do well to give nutritional issues greater attention during the screening and assessment process and avail themselves of what is currently known about the OUD-nutrition link.
