Nutrition for Opioid Overdose

On September 15, 2017 The Academy of Nutrition and Dietetics issued a statement to the CDC regarding Nutrition Interventions and Drug Overdose Response Investigation (DORI) Data Collections. The statement was written by Registered Dietitian Nutritionist David Wiss and essentially advocates the role of nutrition for opioid overdose.
The official statement which is reproduced below can be viewed HERE
Re: Drug Overdose Response Investigation (DORI) Data Collections (Docket No. CDC-2017-0055)
The Academy of Nutrition and Dietetics (the “Academy”) appreciates the opportunity to submit comments to the Centers for Disease Control and Prevention (CDC) in response to the data collection published in the July 17, 2017 Federal Register regarding the Drug Overdose Response Investigation (DORI) Data Collections (Docket No. CDC-2017-0055). The Academy is the world’s largest organization of food and nutrition professionals, with more than 100,000 members comprised of registered dietitian nutritionists (RDNs), nutrition and dietetic technicians, registered (NDTRs), and advanced-degree nutritionists. We are committed to improving the nation’s health through food and nutrition and providing medical nutrition therapy (MNT) and other nutrition counseling services to meet the health needs of all citizens, including those with eating disorders (EDs) or substance use disorders (SUD).
The Academy supports the proposed data collection as necessary for the proper performance of the functions of the agency, particularly given the practical utility resulting from the collections. We respectfully offer recommendations below from Academy member David A. Wiss, MS, RDN, on behalf of our Behavioral Health Nutrition Dietetic Practice Group for potential improvements to the data collections and as support for the claim that nutrition can play a very important role in promoting wellness during the recovery process, thereby helping to reduce relapse and accidental overdose or death.

Eating Patterns and Substance Use Disorders

There are several studies that document substandard eating patterns during drug use, including inadequate intake leading to micronutrient deficiencies [1-6] and malnutrition [7-11]. Abnormal preference for sweetened foods and beverages have been documented in alcoholics [12-14] and other SUDs [15, 16] particularly opioids [17-25]. While micronutrient deficiencies and malnutrition are often corrected by abstinence and recovery, dysfunctional eating patterns such as bingeing and night-eating are often exacerbated during sobriety. Early recovery should be considered a critical time to get nutritional support (e.g. dietary counseling) by a qualified professional such as an RDN.
The overlap between SUDs and EDs has received significant attention in the scientific literature [26-41]. Authors have recently begun to suggest that these disorders be treated concurrently rather than separately. In members’ personal experience working in both fields, patients will oscillate between treatments and are seldom treated concurrently. While it is true that RDNs are a requirement for ED treatment, there is no present requirement for RDNs in SUD treatment settings. Based on members’ experience working with SUD treatment centers, the use of RDNs is rare most likely because nutrition services are not covered by insurance for SUD. We note that the failure to address food and body image issues in SUD treatment is likely contributing to poor outcomes.
It is predictable that individuals entering treatment for SUD will find other substances to abuse, including food [42-45], caffeine [46, 47], and nicotine [46, 47]. While some would argue that it makes sense to allow unlimited access to such substances during early recovery, others believe that the lack of nutrition and health standards are contributing to poor treatment outcomes. Evidence suggests that gastrointestinal health is linked to mental health [48-51] with strong implications for anxiety and depression. Given what is known about the importance of gut health, it seems that improved health and nutrition should be considered a prime intervention for SUD recovery. RDNs in treatment settings are highly qualified to discuss health habits including caffeine and nicotine in the context of nutrition and gastrointestinal health.

Nutrition Education and Interventions During Treatment

Several studies have demonstrated links between nutrition education and positive outcomes in SUD treatment settings [52-57]. Some of the studies have suggested that nutrition education has led to reduced rates of relapse, but higher quality research with greater sample sizes are needed to confirm these findings. Given the opioid epidemic and alarming number of overdose and deaths, however, it seems unwise to wait for more data before using nutrition as an intervention strategy.
Nutrition interventions during recovery may promote abstinence and prevent or minimize the onset of chronic illness, improving resource allocation. A review article from the United Kingdom on the role of healthy eating advice as part of drug treatment in prisons concluded that “substance-misuse is a major factor in recidivism and if this could be reduced through improvement of nutritional status, it could be a cost effective means of helping to tackle this problem” [58]. Given the opioid epidemic, public health measures necessitating nutrition standards in treatment settings should be considered critical. There is a timely need for specialized nutrition expertise in SUD treatment centers, and RDNs are highly qualified for the job.


  1. 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.
  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. 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.
  4. Santolaria-Fernandez, F.J., et al., Nutritional assessment of drug addicts. Drug Alcohol Depend, 1995. 38(1): p. 11-8.
  5. Varela, P., et al., Human immunodeficiency virus infection and nutrtiional status in female drug addicts undergoing detoxification: anthropometric and immunologic assessments. Am J Clin Nutr, 1997. 191997(66): p. 504S-508S.
  6. 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.
  7. 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.
  8. 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.
  9. 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).
  10. Nazrul Islam, S.K., et al., Nutritional status of drug addicts undergoing detoxification: prevalence of malnutrition and influence of illicit drugs and lifestyle. Br J Nutr, 2002. 88(5): p. 507-13.
  11. 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.
  12. D., M., et al., Carbohydrate craving by alcohol-dependent men during sobriety: Relationship to nutrition and serotonergic function. Alcoholism: Clinical and Experimental Research, 2000. 24(5): p. 635-643.
  13. Kampov-Polevoy, A., J.C. Garbutt, and D. Janowsky, Evidence of preference for a high-concentation sucrose solution in alcoholic men. Am J Psychiatry, 1997. 154(2): p. 269-270.
  14. 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.
  15. Janowsky, D.S., O. Pucilowski, and M. Buyinza, Preference for higher sucrose concentrations in cocaine abusing-dependent patients. J Psychiatr Res, 2003. 37(1): p. 35-41.
  16. Hamamoto, D.T. and N.L. Rhodus, Methamphetamine abuse and dentistry. Oral Dis, 2009. 15(1): p. 27-37.
  17. 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.
  18. Canan, F., et al., Eating disorders and food addiction in men with heroin use disorder: a controlled study. Eat Weight Disord, 2017.
  19. McDonald, E., Hedonic mechanisms for weight changes in medication assisted treatment for opioid addiction. 2017.
  20. 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.
  21. Neale, J., et al., Eating patterns among heroin users: a qualitative study with implications for nutritional interventions. Addiction, 2012. 107(3): p. 635-41.
  22. Nolan, L.J. and L.M. Scagnelli, Preference for sweet foods and higher body mass index in patients being treated in long-term methadone maintenance. Subst Use Misuse, 2007. 42(10): p. 1555-66.
  23. Richardson, R.A. and K. Wiest, A Preliminary Study Examining Nutritional Risk Factors, Body Mass Index, and Treatment Retention in Opioid-Dependent Patients. J Behav Health Serv Res, 2015. 42(3): p. 401-8.
  24. Waddington, F., et al., Nutritional intake of opioid replacement therapy patients in community pharmacies: A pilot study. Nutrition & Dietetics, 2015. 72(3): p. 276-283.
  25. 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.
  26. 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.
  27. 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.
  28. Bulik, C.M., M. Slof, and P. Sullivan, Comorbidity of eating disorders and substance-related disorders. Medical Psychiatry, 2004. 27: p. 317-348.
  29. Calero-Elvira, A., et al., Meta-analysis on drugs in people with eating disorders. Eur Eat Disord Rev, 2009. 17(4): p. 243-59.
  30. Cohen, L.R., et al., Survey of eating disorder symptoms among women in treatment for substance abuse. Am J Addict, 2010. 19(3): p. 245-51.
  31. 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.
  32. Czarlinski, J.A., D.M. Aase, and L.A. Jason, Eating disorders, normative eating self-efficacy and body image self-efficacy: women in recovery homes. Eur Eat Disord Rev, 2012. 20(3): p. 190-5.
  33. Dennis, A.B., T. Pryor, and T.D. Brewerton, Integrated Treatment Principles and Strategies for Patients with Eating Disorders, Substance Use Disorder, and Addictions. 2014: p. 461-489.
  34. Eichen, D.M., et al., Weight perception, substance use, and disordered eating behaviors: comparing normal weight and overweight high-school students. J Youth Adolesc, 2012. 41(1): p. 1-13.
  35. 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.
  36. Grilo, C.M., et al., Eating disorders in female inpatients with versus without substance use disorders. Addict Behav, 1995. 20(2): p. 255-260.
  37. Ho, V., S. Arbour, and J.M. Hambley, Eating Disorders and Addiction: Comparing Eating Disorder Treatment Outcomes Among Clients With and Without Comorbid Substance Use Disorder. Journal of Addictions Nursing, 2011. 22(3): p. 130-137.
  38. 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.
  39. Root, T.L., et al., Substance use disorders in women with anorexia nervosa. Int J Eat Disord, 2010. 43(1): p. 14-21.
  40. 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.
  41. Specter, S.E. and D.A. Wiss, Muscle Dysmorphia: Where Body Image Obsession, Compulsive Exercise, Disordered Eating, and Substance Abuse Intersect in Susceptible Males. 2014: p. 439-457.
  42. Michaelides, M., et al., Translational neuroimaging in drug addiction and obesity. ILAR Journal, 2012. 53(1): p. 59-68.
  43. Muele, A., T. Hermann, and A. Kubler, Food addiction in overweight and obese adolescents seeking weight-loss treatment. European Eating Disorders Review, 2015. 23: p. 193-198.
  44. Nair, S.G., et al., The neuropharmacology of relapse to food seeking: methodology, main findings, and comparison with relapse to drug seeking. Prog Neurobiol, 2009. 89(1): p. 18-45.
  45. Volkow, N.D. and R.A. Wise, How can drug addiction help us understand obesity? Nat Neurosci, 2005. 8(5): p. 555-60.
  46. Junghanns, K., et al., The consumption of cigarettes, coffee and sweets in detoxified alcoholics and its association with relapse and a family history of alcoholism. Eur Psychiatry, 2005. 20(5-6): p. 451-5.
  47. Yudko, E. and S.I. McNiece, Relationship between coffee use and depression and anxiety in a population of adult polysubstance abusers. J Addict Med, 2014. 8(6): p. 438-42.
  48. Huang, R., K. Wang, and J. Hu, Effect of Probiotics on Depression: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Nutrients, 2016. 8(8).
  49. Rieder, R., et al., Microbes and mental health: A review. Brain Behav Immun, 2017.
  50. Singh, R.K., et al., Influence of diet on the gut microbiome and implications for human health. J Transl Med, 2017. 15(1): p. 73.
  51. 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.
  52. 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.
  53. 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.
  54. 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.
  55. 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.
  56. Cowan, J.A. and C.M. Devine, Diet and Body Composition Outcomes of an Environmental and Educational Intervention among Men in Treatment for Substance Addiction. Journal of Nutrition Education and Behavior, 2013. 45(2): p. 154-158.
  57. 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.
  58. Sandwell, H. and M. Wheatley, Healthy eating advice as part of drug treatment in prisons. Prison Service Journal, 2009.

Dr. David Wiss became a Registered Dietitian Nutritionist (RDN) in 2013 and founded Nutrition in Recovery, a group practice of RDNs specializing in treating eating and substance use disorders. In 2017, David received the “Excellence in Practice” award at the National Food and Nutrition Conference and Expo. The California Academy of Nutrition and Dietetics awarded him the “Emerging Dietetic Leader Award” in 2020. He earned his Ph.D. from UCLA’s Fielding School of Public Health in the Community Health Sciences department (with a minor in Health Psychology) by investigating the links between adverse childhood experiences and various mental health outcomes among socially disadvantaged men. His treatment philosophy is based on a biopsychosocial model which incorporates an understanding of biological mechanisms, psychological underpinnings, and contextual factors that integrate the social determinants of health. Wise Mind Nutrition is an app-based interactive treatment program available for download now -

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